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","B","C","D"]

Explanation

A. Blood pressure: The client’s blood pressure (92/60 mm Hg) is low, which is concerning, especially with tachycardia (HR 106). This may indicate hypovolemia or shock, which requires immediate attention.
B. BUN level: The BUN level (25 mg/dL) is elevated above the normal range, which could indicate dehydration or kidney dysfunction, often seen in conditions like gastrointestinal obstruction or sepsis.
C. Potassium level: The potassium level (3.3 mEq/L) is below the normal range (3.5 to 5 mEq/L), which can contribute to arrhythmias and muscle weakness, often a result of vomiting, diarrhea, or dehydration.
D. Abdominal findings: The high-pitched bowel sounds and tenderness are consistent with an intestinal obstruction, and further assessment and intervention are necessary to manage the condition effectively.
E. WBC count: The WBC count (9,000/mm³) is within the normal range, suggesting no active infection or inflammation at the moment.
F. Breath sounds: Bilateral breath sounds are clear, which suggests no current respiratory issues or pneumonia, allowing the focus to remain on gastrointestinal findings.

A. Current medication prescriptions B. Primary health problem C. Number of family members who have visited D. Admission vital signs from 1 week ago E. Scheduled times for dressing changes

Correct Answer is ["A","B","E"]

Explanation

A. Current medication prescriptions: Ensures continuity of care and proper medication administration in the ICU.
B. Primary health problem: Provides the ICU team with context about the client’s current condition and reason for transfer.
C. Number of family members who have visited: This is not clinically relevant to the client's care.
D. Admission vital signs from 1 week ago: Historical vitals are not as critical as current or recent findings.
E. Scheduled times for dressing changes: Provides critical information about ongoing wound care needs.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is assisting with the care of a client. Exhibits The nurse is collecting data on the client. Which of the following findings require follow-up? Select all that apply.

Correct Answer is ["A","B","C","D"]

Explanation

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Correct Answer is ["A","B","E"]

Explanation

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