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 C

Explanation

A. "Cervical cancer screenings should begin at age 40.": Screenings start at age 21, not 40.
B. "Plan to continue cervical cancer screenings for the rest of your life.": Screenings can stop after age 65 if the client has had adequate prior screening and no high-risk factors.
C. "You should get a Papanicolaou (Pap) test and human papillomavirus test every 5 years.": Current guidelines recommend Pap and HPV co-testing every 5 years for women aged 30–65.
D. "If you are immunized against human papillomavirus, you don't need cervical cancer screenings.": HPV vaccination reduces risk but does not eliminate the need for routine screening.

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?

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Naxlex Comprehensive Predictor Exams

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