A nurse is caring for a client who is 6 hr postoperative following a bowel resection. Which of the following findings is the priority for the nurse to report?

The client arouses easily but quickly falls back asleep.

There is 20 mL of dark red drainage from the wound drainage device over the past 4 hr.

There is 60 mL of dark yellow urine from the indwelling urinary catheter over the past 4 hr.

The client reports a pain level of 6 on a scale from 0 to 10 at the incision site.

Answer and Explanation

The Correct Answer is A

A. The client arouses easily but quickly falls back asleep. This could indicate a potential complication, such as a postoperative haemorrhage, hypovolemia which can lead to decreased perfusion and oxygenation.
B. 20 mL of dark red drainage over 4 hours: This is expected postoperative output.
C. 60 mL of dark yellow urine over 4 hours: This is a low output but not immediately critical compared to potential hypoxia.
D. Pain level of 6/10 at the incision site: Pain is expected and manageable with interventions, making it less critical.

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Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

Open the splint: Reduces pressure and alleviates compartment syndrome.

Place the client on NPO status: Anticipated in preparation for possible surgery (e.g., fasciotomy).

Place the leg in a dependent position: Contraindicated as it can worsen swelling and increase pressure.

Obtain a urinalysis: Necessary to monitor for myoglobinuria, a potential complication of muscle damage in compartment syndrome.

A. Unable to repeat the names of three common objects the nurse names. B. Unable to answer a judgment question correctly. C. Unable to remember their adult children's names. D. Unable to remain fully awake while answering questions.

Correct Answer is D

Explanation

A. "Unable to repeat the names of three common objects the nurse names.": This indicates possible short-term memory issues but is less critical than a reduced level of consciousness.
B. "Unable to answer a judgment question correctly.": Poor judgment is less immediately concerning compared to reduced consciousness.
C. "Unable to remember their adult children's names.": Long-term memory loss is not as urgent as changes in consciousness or neurological status.
D. "Unable to remain fully awake while answering questions.": This finding suggests a potential decline in neurological status, such as increased intracranial pressure or a brain injury, and is the priority.

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A nurse is caring for a client who is 6 hr postoperative following a bowel resection. Which of the following findings is the priority for the nurse to report?

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Naxlex Comprehensive Predictor Exams

Correct Answer is {"A":{"answers":"A"},"B":{"answers":"A"},"C":{"answers":"B"},"D":{"answers":"A"}}

Explanation

A nurse in an assisted living facility is collecting data from an older adult client who fell in their room and hit their head on the dresser. Which of the following findings is the nurse's priority?

Correct Answer is D

Explanation

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