A nurse is caring for a client who is 2 hr postoperative. Which of the following findings should the nurse report to the provider?

The client has a wound dressing saturated with sanguinous drainage after it was reinforced.

The client has an oxygen saturation level of 96% after oxygen 2 L/min via nasal cannula was applied.

The client reports a pain level of 2 on a 0 to 10 scale after administration of pain medication.

The client has a urine output of 50 mL/hr after removal of the indwelling urinary catheter.

Answer and Explanation

The Correct Answer is A

Choice A reason: Saturated sanguinous drainage post-reinforcement signals excessive bleeding, potentially indicating hemorrhage or poor wound healing. Two hours postoperative, this suggests vascular injury or coagulopathy, requiring urgent provider notification to prevent hypovolemia, infection, or further complications in the surgical site.
Choice B reason: Oxygen saturation of 96% on 2 L/min nasal cannula is normal (95-100%), indicating stable respiratory status. This does not require reporting, as it reflects effective oxygenation post-surgery, with oxygen therapy appropriately supporting recovery without signs of respiratory distress.
Choice C reason: A pain level of 2/10 post-medication indicates effective pain control, not warranting immediate reporting. Postoperative pain management targets comfort (<4/10), and this level suggests successful analgesia, with no evidence of complications like nerve injury requiring provider intervention.
Choice D reason: Urine output of 50 mL/hr is normal (>30 mL/hr) post-catheter removal, indicating adequate renal perfusion. This does not require reporting, as it reflects normal kidney function and hydration status in the early postoperative period, absent other concerning symptoms.

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Correct Answer is D

Explanation

Choice A reason: Amputation is not a contraindication for kidney donation, as it does not affect kidney function or surgical risks. Physical disability, if stable, does not preclude donation, so this condition is irrelevant to eligibility, making it incorrect.
Choice B reason: Primary glaucoma does not impact kidney function or donation safety. It is an eye condition unrelated to systemic health risks for donation, so it is not a contraindication, making this an incorrect choice for exclusion.
Choice C reason: Osteoarthritis, if mild, is not a contraindication for kidney donation, as it does not affect renal or surgical outcomes. Severe cases may pose mobility issues, but this is not typical, so it is incorrect as a contraindication.
Choice D reason: Hypertension is a contraindication for kidney donation, as it increases risks of renal damage and cardiovascular complications post-donation. It compromises long-term kidney function, aligning with transplant guidelines, making it the correct condition to identify.

A. Reassure the client that she can have additional children. B. Discourage the client from allowing friends to see the newborn. C. Offer to take pictures of the newborn for the client. D. Advise the client to avoid discussing the stillbirth with family.

Correct Answer is C

Explanation

Choice A reason: Reassuring the client about future children minimizes her current grief and loss, which is inappropriate during initial grieving. This dismisses the emotional significance of the stillbirth, potentially causing distress, making it an insensitive and incorrect action.
Choice B reason: Discouraging friends from seeing the newborn restricts the client’s support system and grieving process. Allowing such interactions can provide closure and comfort, so this action is counterproductive and insensitive, making it incorrect for supporting grief.
Choice C reason: Offering to take pictures of the newborn provides a tangible memory, supporting the client’s grieving process. This sensitive intervention validates the loss and aids emotional healing, aligning with best practices for stillbirth care, making it the correct action.
Choice D reason: Advising against discussing the stillbirth isolates the client and hinders grief processing. Open communication with family fosters support and healing, so this action is harmful and contradicts grief support principles, making it incorrect.

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A nurse is caring for a client who is 2 hr postoperative. Which of the following findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for a client who has end-stage kidney disease. The client’s adult child asks the nurse about becoming a living kidney donor for their parent. Which of the following conditions in the child’s medical history should the nurse identify as a contraindication to the procedure?

Correct Answer is D

Explanation

A nurse is caring for a client who has experienced a stillbirth. Which of the following actions should the nurse take during the initial grieving process?

Correct Answer is C

Explanation

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