The nurse is caring for a client who is 24 hours postoperative. Which finding would require immediate attention by the nurse?

Heart rate of 77

Urine output of 300 ml in 24-hour

Temperature of 99.2 oral

Pain rating 3 on 1-10 pain scale

Answer and Explanation

The Correct Answer is B

A. Heart rate of 77: A heart rate of 77 bpm is within normal resting range for many adults and would not typically demand immediate intervention.

B. Urine output of 300 ml in 24-hour: 300 ml in 24 hours is markedly low (oliguria); inadequate urine output may indicate hypovolemia, renal impairment, or obstruction and requires immediate assessment and intervention.

C. Temperature of 99.2 oral: 99.2°F is a low-grade elevation and can be common after surgery; it is not usually an immediate emergency at 24 hours post-op.

D. Pain rating 3 on 1–10 pain scale: A pain score of 3 is mild/moderate and typically managed with routine analgesia and reassessment rather than immediate urgent action.

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Correct Answer is C

Explanation

A. Pallor: Pallor means paleness of the skin due to decreased blood flow or hemoglobin (e.g., anemia, shock); it appears pale, not bluish.

B. Jaundice: Jaundice is yellow discoloration caused by elevated bilirubin (liver disease/hemolysis); it is yellow, not blue.

C. Cyanosis: Cyanosis is a bluish or purplish discoloration of the skin and mucous membranes from increased deoxygenated hemoglobin or poor perfusion and is the appropriate term to document when skin appears blue.

D. Erythema: Erythema is redness of the skin from increased blood flow, inflammation, or fever; it does not describe a bluish discoloration.

A. Due to increase in physical activity B. Increase in subcutaneous body fat and metabolic rate C. Due to an increase in protein intake in their diet D. Decrease in subcutaneous body fat and metabolic rate

Correct Answer is D

Explanation

A. Due to increase in physical activity: Increased activity tends to raise body temperature; older adults typically have lower activity levels, so this does not explain a lower baseline temperature.

B. Increase in subcutaneous body fat and metabolic rate: Increased subcutaneous fat and metabolic rate would tend to conserve heat and raise temperature; aging is associated with the opposite change.

C. Due to an increase in protein intake in their diet: Dietary protein does not directly cause a lower core body temperature in older adults.

D. Decrease in subcutaneous body fat and metabolic rate: Age-related loss of subcutaneous fat and a lower metabolic rate reduce heat production and insulation, contributing to a tendency toward lower body temperature.

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The nurse is caring for a client who is 24 hours postoperative. Which finding would require immediate attention by the nurse?

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