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 C

Explanation

Choice A reason: Dehydration is not directly associated with gastroesophageal reflux, which involves gastric acid backflow. Dehydration affects fluid balance, not reflux mechanisms, so this statement is inaccurate and irrelevant to preterm contractions, making it incorrect.
Choice B reason: Dehydration is not caused by decreased hemoglobin and hematocrit; rather, it may elevate these due to hemoconcentration. This statement reverses the relationship, making it factually incorrect and unrelated to preterm labor risks.
Choice C reason: Dehydration can increase preterm labor risk by reducing uterine blood flow and triggering contractions via oxytocin release. This evidence-based link supports hydration as a preventive measure, making it the correct statement for teaching in this scenario.
Choice D reason: Dehydration is treated with fluid replacement, not calcium supplements, which address bone health or specific deficiencies. This treatment is irrelevant to dehydration or preterm labor, making it an incorrect and inappropriate recommendation.

A. I expect this medication to raise my blood pressure. B. I know it will be a couple of weeks before the medication helps me feel better. C. I should take this medication on an empty stomach. D. This medication will help me sleep if I take it in the morning.

Correct Answer is B

Explanation

Choice A reason: Amitriptyline, a tricyclic antidepressant, typically causes hypotension via alpha-adrenergic blockade, not hypertension. Expecting blood pressure elevation shows misunderstanding, as its cardiovascular effects require monitoring for orthostatic changes, not hypertensive risks, in depression treatment.
Choice B reason: Acknowledging a 2-4 week delay for amitriptyline’s effect shows understanding, as tricyclics increase synaptic serotonin and norepinephrine gradually, requiring neuroplastic changes for mood improvement. This reflects accurate knowledge of the drug’s onset, critical for managing expectations in depression therapy.
Choice C reason: Taking amitriptyline on an empty stomach is incorrect, as food reduces gastrointestinal side effects like nausea. Its absorption is unaffected by food, but taking it with meals improves tolerability, indicating a misunderstanding of administration guidelines for effective therapy.
Choice D reason: Morning dosing of amitriptyline is incorrect, as its sedative effects, via histamine blockade, are best utilized at bedtime to aid sleep. Morning use may cause daytime drowsiness, reducing adherence, indicating a misunderstanding of its pharmacological profile in depression management.

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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 providing teaching to a client who is experiencing preterm contractions and dehydration. Which of the following statements should the nurse make?

Correct Answer is C

Explanation

A nurse is providing teaching to a client who has a depressive disorder and a new prescription for amitriptyline. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is B

Explanation

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