The nurse is assessing a client in the immediate post-operative setting. Which of the following finding requires priority intervention to prevent long-term complications?

Patient's refusal to cough, deep breathe, and use their incentive spirometer due to pain

Urine output of 40 mL/hr and clear yellow after having their Foley catheter removed

Patient ambulating short distances and performing range of motion exercises alter pain is controlled

Hypoactive bowel sounds 2 hours post-operative.

Answer and Explanation

The Correct Answer is A

A) Patient's refusal to cough, deep breathe, and use their incentive spirometer due to pain:
The patient’s refusal to perform these respiratory exercises could lead to serious complications such as atelectasis, pneumonia, and other respiratory issues. Coughing, deep breathing, and using the incentive spirometer are essential to prevent postoperative respiratory complications, especially if the patient is at higher risk for lung issues due to immobility or anesthesia. This needs immediate intervention to ensure the patient understands the importance of these activities and to address the pain issue, potentially with additional pain management or support.

B) Urine output of 40 mL/hr and clear yellow after having their Foley catheter removed:
A urine output of 40 mL/hr is within normal limits for a post-operative patient, and the clear yellow color indicates that the urine is not concentrated or indicative of infection. While monitoring urine output is important postoperatively, this finding suggests adequate renal function and does not indicate an immediate risk for long-term complications.

C) Patient ambulating short distances and performing range of motion exercises after pain is controlled:
Early ambulation and range of motion exercises are encouraged after surgery to promote circulation, prevent blood clots, and support overall recovery. It indicates that the patient is progressing in their recovery and actively participating in post-operative rehabilitation, which is a positive sign and does not need urgent intervention.

D) Hypoactive bowel sounds 2 hours post-operatively:
This is expected immediately after surgery, especially if the patient underwent abdominal surgery or received general anesthesia, which can temporarily reduce bowel motility. Hypoactive bowel sounds within the first few hours post-surgery are a normal response to anesthesia and do not require urgent intervention. The nurse should continue to monitor the patient’s bowel function, but this finding is not a priority in the immediate postoperative period.

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Correct Answer is A

Explanation

A. Troponins I & T:
Troponins I and T are the most specific biomarkers for myocardial damage. These proteins are released into the bloodstream when the heart muscle is injured, such as during a myocardial infarction (MI). Troponins remain elevated for a prolonged period (typically up to 1-2 weeks) after myocardial injury, making them highly sensitive for detecting both acute and recent myocardial damage. Because of their high specificity for heart muscle, they are considered the gold standard for diagnosing acute myocardial infarction.

B. Creatine Kinase:
Creatine kinase (CK) is an enzyme found in the heart, brain, and skeletal muscle. While CK-MB (the heart-specific isoenzyme) can be elevated in cases of myocardial damage, it is less specific than troponins because it can also be elevated due to skeletal muscle injury or other conditions. CK-MB levels rise more rapidly than troponins but return to baseline within 48-72 hours, making it less useful for detecting myocardial damage over a longer period.

C. C-Reactive Protein (CRP):
C-Reactive Protein (CRP) is an acute-phase reactant produced by the liver in response to inflammation or tissue injury. While CRP levels can be elevated in various inflammatory conditions, including atherosclerosis, it is not specific to myocardial damage. Elevated CRP is associated with increased risk for cardiovascular events but does not provide specific information about acute myocardial injury, making it less helpful for diagnosing myocardial infarction.

D. Myoglobin:
Myoglobin is an oxygen-binding protein found in both skeletal and cardiac muscle. While it is an early marker that rises rapidly after muscle injury, it lacks specificity for myocardial damage because it is also released from skeletal muscle. Myoglobin levels peak quickly (within 1-4 hours of injury) and return to baseline within 24 hours, so it is not as useful for diagnosing a myocardial infarction or monitoring long-term cardiac injury.

A. Complete blood count (CBC) B. Electroencephalogram (EEG) C. Computed tomography (CT) scan D. Chest radiograph (chest x-ray)

Correct Answer is C

Explanation

A) "Complete blood count (CBC)":
. A CBC can provide important information about the patient's overall health, including potential signs of infection, anemia, or other underlying conditions. However, in the context of acute neurological symptoms such as left-sided weakness, CT scan is the priority test because it will help quickly determine if there is an acute neurological event, such as a stroke or hemorrhage. While a CBC might be useful later to assess for underlying
conditions or potential causes, it is not the first test to perform in this scenario.

B) "Electroencephalogram (EEG)":
. An EEG is primarily used to diagnose and assess seizure activity or epileptic disorders. While seizures can cause neurological deficits, the patient's sudden onset of left-sided weakness is more suggestive of a stroke, not a seizure. The priority is to rule out stroke with a CT scan, not to assess for seizures with an EEG.

C) "Computed tomography (CT) scan":
. A CT scan is the first diagnostic test to perform in patients with acute neurological deficits such as sudden-onset weakness, especially when a stroke is suspected. A CT scan can quickly detect if the cause is an ischemic stroke (lack of blood flow due to a clot) or a hemorrhagic stroke (bleeding in the brain). Time is critical in the management of stroke, as early intervention with treatments like tPA (tissue plasminogen activator) for ischemic stroke can greatly improve outcomes. The CT scan can help determine if the patient is a candidate for thrombolysis or if other interventions are needed.

D) "Chest radiograph (chest x-ray)":
. While a chest x-ray can be useful for diagnosing respiratory issues, such as pneumonia or congestion, it is not helpful in evaluating the cause of acute neurological symptoms like left-sided weakness. The priority test is a CT scan to evaluate the brain and rule out conditions like stroke or hemorrhage, not a chest x-ray.

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The nurse is assessing a client in the immediate post-operative setting. Which of the following finding requires priority intervention to prevent long-term complications?

Nursing Test Bank

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Correct Answer is A

Explanation

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Correct Answer is C

Explanation

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