A nurse is caring for a client who is 4 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

Urine output 25 mL/hr

Heart rate 68/min

Hypoactive bowel sounds

Serosanguineous drainage on surgical dressing

Answer and Explanation

The Correct Answer is A

A. Urine output 25 mL/hr: Urine output less than 30 mL/hr is considered inadequate, especially after surgery. This could indicate possible renal insufficiency or hypovolemia, requiring immediate attention.

B. Heart rate 68/min: A heart rate of 68/min falls within the normal adult range (60-100 beats per minute). This finding is generally considered stable and does not typically indicate an immediate complication requiring urgent reporting to the provider in a postoperative client.

C. Hypoactive bowel sounds: Hypoactive bowel sounds are common in the immediate postoperative period, especially after abdominal surgery. This occurs due to the effects of anesthesia and bowel manipulation.

D. Serosanguineous drainage on surgical dressing: Serosanguineous drainage is typical in the early postoperative period and usually decreases over time. It’s not abnormal unless the amount increases significantly or the drainage becomes purulent.

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Correct Answer is A

Explanation

A. Place a vibrating tuning fork against the midline vertex of the client's head: The Weber test is performed by placing a vibrating tuning fork on the midline of the client's forehead or vertex of the head. This tests for lateralization of sound, helping to distinguish between conductive and sensorineural hearing loss based on which ear hears the sound louder.

B. Have the client repeat a phrase spoken by the nurse while the nurse's mouth is hidden: This action refers to the "speech discrimination test" rather than the Weber test. It is not part of the Weber test, which is specifically used to assess the lateralization of sound.

C. Whisper words for the client to identify: This refers to a different hearing test, called the "whisper test," used to assess hearing ability, not the Weber test. The Weber test specifically uses a tuning fork to assess how sound is heard by the client.

D. Ask the client to occlude one ear with a finger: While blocking one ear can be used in other tests (like Rinne's test), it is not necessary for the Weber test, which involves placing the tuning fork in the center of the head.

A. Apply a moisture barrier ointment to the area in contact with urine. B. Assist with toileting every 4 hr while awake. C. Instruct the client to consume fluids between 0600 and 2200. D. Cleanse the skin with antibacterial soap and hot water after each incontinence episode.

Correct Answer is A

Explanation

A. Apply a moisture barrier ointment to the area in contact with urine: Applying a moisture barrier ointment is an essential intervention to protect the skin from moisture-related irritation and breakdown. This helps prevent skin damage from prolonged exposure to urine.

B. Assist with toileting every 4 hr while awake: While regular toileting is important for managing urinary incontinence, the client should be encouraged to use the bathroom based on individual needs. Toileting every 4 hours may not meet the client’s needs for more frequent voiding.

C. Instruct the client to consume fluids between 0600 and 2200: Limiting fluid intake to specific hours is not recommended unless there is a medical need. Adequate hydration is essential, and restricting fluid intake could lead to dehydration or urinary tract infections.

D. Cleanse the skin with antibacterial soap and hot water after each incontinence episode: Antibacterial soap and hot water can be too harsh on the skin, potentially leading to dryness and irritation. It’s better to use mild soap and warm water to cleanse the skin gently.

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A nurse is caring for a client who is 4 hr postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

Nursing Test Bank

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