A postoperative patient has an abdominal drain. What assessment by the nurse indicates that goals for the priority patient problems related to the drain are being met?

There is no redness, warmth, or drainage at the insertion site.

Drainage from the surgical site is 30 mL less than yesterday.

The patient reports adequate pain control with medications.

Urine is clear yellow and urine output is greater than 40 mL/hr

Answer and Explanation

The Correct Answer is A

A. There is no redness, warmth, or drainage at the insertion site.

This assessment is crucial for evaluating the status of the abdominal drain site. The absence of redness, warmth, or drainage suggests that the insertion site is healing well without signs of infection or inflammation. It indicates that the drain is functioning properly and that there are no immediate complications related to the drain insertion. This assessment directly addresses the goals related to monitoring the drain site for signs of infection or dysfunction.

B. Drainage from the surgical site is 30 mL less than yesterday.

Monitoring the drainage output from the surgical site is important to assess for changes in drainage patterns. A decrease in drainage volume may indicate reduced fluid accumulation at the surgical site, potentially reflecting improved healing and decreased need for drainage. However, while this assessment is valuable, it is not as directly related to assessing the status of the drain itself or evaluating complications at the insertion site as option A.

C. The patient reports adequate pain control with medications.

Pain control is an essential aspect of postoperative care, but it is not specifically related to assessing the functionality or complications of the abdominal drain. While pain management is important for patient comfort and recovery, it does not directly address the goals related to monitoring the drain site for signs of infection, leakage, or other complications.

D. Urine is clear yellow, and urine output is greater than 40 mL/hr.

While monitoring urine output and characteristics is important for assessing renal function and hydration status, it is not directly related to assessing the abdominal drain or its complications. Clear yellow urine and adequate urine output are generally positive indicators but do not provide specific information about the functionality or status of the drain.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

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

Explanation

A serum potassium level of 3.2 mEq/L indicates hypokalemia, which is a potential complication of inhibiting aldosterone secretion and release. Aldosterone plays a key role in potassium regulation in the body by promoting potassium excretion in the kidneys. When aldosterone secretion is inhibited, potassium excretion decreases, leading to an accumulation of potassium in the bloodstream and resulting in hypokalemia. Symptoms of hypokalemia may include muscle weakness, cramping, irregular heartbeat, and fatigue.

B. Urine output of 1,200 mL in the last 2 hours:

This option does not directly relate to complications of inhibiting aldosterone secretion. A urine output of 1,200 mL in the last 2 hours indicates adequate urine production, which is generally a positive sign. However, in the context of inhibiting aldosterone secretion, the nurse would be more concerned about decreased urine output due to potential renal effects.

C. Blood osmolality of 250 mOsm/kg (250 mmol/kg):

Blood osmolality within the normal range (usually around 275-295 mOsm/kg) is not directly associated with complications of inhibiting aldosterone secretion. Blood osmolality reflects the concentration of solutes in the blood and is regulated by various factors, including water balance, electrolyte levels, and hormonal regulation. Inhibiting aldosterone secretion primarily affects electrolyte balance rather than blood osmolality.

D. Urine output of 25 mL/hr:

A urine output of 25 mL/hr is considered low and may indicate decreased renal perfusion or impaired kidney function. Inhibiting aldosterone secretion can affect renal function and urine output, leading to decreased urine production. Reduced urine output can contribute to fluid and electrolyte imbalances and may be a concern in patients with inhibited aldosterone secretion.

E. Serum potassium level of 5.4 mEq/L:

A serum potassium level of 5.4 mEq/L indicates hyperkalemia, which is another potential complication of inhibiting aldosterone secretion. Aldosterone helps regulate potassium levels by promoting potassium excretion in the kidneys. When aldosterone secretion is inhibited, potassium excretion decreases, leading to an accumulation of potassium in the bloodstream and resulting in hyperkalemia. Symptoms of hyperkalemia may include muscle weakness, irregular heartbeat, nausea, and numbness or tingling.

A. Blood pressure B. Bowel sounds C. Level of consciousness D. Urine output E. Platelet count

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

Explanation

A. Blood pressure:

Monitoring blood pressure is a crucial aspect of evaluating fluid resuscitation in burn patients. Adequate fluid resuscitation should help maintain stable blood pressure levels within an acceptable range. Hypotension (low blood pressure) can indicate inadequate fluid resuscitation, leading to poor tissue perfusion and organ function. On the other hand, hypertension (high blood pressure) may suggest fluid overload, which can lead to complications such as pulmonary edema. Therefore, regular monitoring of blood pressure helps assess the effectiveness of fluid resuscitation and guides adjustments in fluid administration rates.

B. Bowel sounds:

While bowel sounds are important indicators of gastrointestinal motility and function, they are not directly used to evaluate the success of fluid resuscitation in burn patients. Bowel sounds may be assessed for other reasons, such as postoperative recovery or gastrointestinal conditions, but they do not provide specific information about fluid resuscitation status or tissue perfusion.

C. Level of consciousness:

Assessing the client's level of consciousness is crucial during fluid resuscitation for burns. Changes in consciousness, such as confusion, lethargy, or altered mental status, can indicate inadequate tissue perfusion and oxygenation. A clear and responsive level of consciousness suggests adequate fluid resuscitation and perfusion to vital organs, while alterations in consciousness may prompt further evaluation and adjustment of fluid resuscitation strategies.

D. Urine output:

Monitoring urine output is a key parameter in evaluating fluid resuscitation in burn patients. Adequate urine output (0.5 to 1 mL/kg/hr in adults) indicates sufficient renal perfusion and function, suggesting effective fluid resuscitation. Decreased urine output or oliguria may indicate inadequate fluid resuscitation, renal impairment, or hypovolemia, requiring reassessment and potential adjustments in fluid administration rates or type of fluids used.

E. Platelet count:

Platelet count is an important component of the complete blood count (CBC) and is used to assess clotting function and risk of bleeding. However, platelet count is not specifically used to evaluate the success of fluid resuscitation in burn patients. While clotting parameters may be monitored in burn patients, including platelet count, they are not direct indicators of fluid resuscitation status or tissue perfusion. Other laboratory parameters, such as hemoglobin, hematocrit, electrolyte levels, and arterial blood gases, may be monitored to assess the effectiveness of fluid resuscitation.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A postoperative patient has an abdominal drain. What assessment by the nurse indicates that goals for the priority patient problems related to the drain are being met?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse assesses a patient who is prescribed a medication that inhibits aldosterone secretion and release. For which potential complications will the nurse assess? (Select all that apply.)

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

Explanation

A nurse is caring for a client during fluid resuscitation for burns. Which of the following are used to evaluate the success of fluid resuscitation? (Select all that apply.)

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

Explanation

A nurse is caring for a client during the fluid resuscitation phase of burn management. Which of the following is the best method for assessing the results of the fluid resuscitation?

A nurse evaluates the following arterial blood gas values in a patient: pH 7.48, PaO 98 mm Hg, PaCO 28 mm Hg, and HCO - 22 mEq/L (22 mmol/L). Which patient condition does the nurse correlate with these results?

A 30-year-old African American had surgery 6 months ago and the incision site is now raised, indurated, and shiny. This is most likely which type of tissue growth?

After teaching a patient who is at risk for the formation of pressure ulcers, a nurse assesses the patients understanding. Which dietary choice by the patient indicates a good understanding of the teaching?

A postoperative patient has an abdominal drain. What assessment by the nurse indicates that goals for the priority patient problems related to the drain are being met?

A nurse recently hired to the preoperative area learns that certain patients are at higher risk for venous thromboembolism (VTE). Which patients are considered to be at high risk? (Select all that apply.)

A nurse is caring for a client with a chronic wound. Which of the following is a systemic cause of chronic wounds?

A nurse reviews the following data in the chart of a patient with burn injuries: Based on the data provided, how would the nurse categorize this patients injuries?