The nurse is planning care for four postoperative clients, each with a different drainage system. Which information, received in report, requires immediate follow-up intervention by the nurse?
30 mL of serous fluid obtained from compression bulb device in last 4 hours.
40 mL per hour of dark, cloudy urine from urinary catheter in last 4 hours.
20 mL of serosanguinous drainage from chest tube in last 8 hours.
No observable drainage from 3-day-old Penrose drain in last 8 hours.
The Correct Answer is D
Choice A reason: 30 mL of serous fluid from a compression bulb device is not a cause for concern. It indicates that the wound is healing and the device is functioning properly.
Choice B reason: 40 mL per hour of dark, cloudy urine from a urinary catheter may indicate dehydration, infection, or hematuria, but it is not an immediate priority. The nurse should monitor the urine output and characteristics, and report any abnormal findings to the provider.
Choice C reason: 20 mL of serosanguinous drainage from a chest tube is expected after thoracic surgery. It reflects the normal inflammatory response and the removal of excess fluid from the pleural space.
Choice D reason: No observable drainage from a 3-day-old Penrose drain is a sign of possible obstruction or infection. The nurse should assess the site for swelling, redness, pain, or purulent drainage, and notify the provider immediately. The Penrose drain should be replaced or removed as soon as possible.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Maintaining in high Fowler's position may help the client breathe easier, but it is not the most important intervention. The client may prefer to lie down or change positions according to their comfort.
Choice B reason: Reporting any change in urine color may indicate dehydration, infection, or kidney problems, but it is not the most important intervention. The client may not have much urine output due to reduced fluid intake and kidney function.
Choice C reason: Keeping mucous membranes moist is the most important intervention, as it can prevent dryness, cracking, and bleeding of the lips, mouth, and throat. The client may have difficulty swallowing and may lose their sense of taste due to the cancer or the treatment. The PN should encourage the family to offer the client sips of water, ice chips, or mouthwash, and to apply lip balm or petroleum jelly.
Choice D reason: Recording the client's daily weight may help monitor the client's nutritional status and fluid balance, but it is not the most important intervention. The client may have significant weight loss due to the cancer or the treatment, and may not want to eat or drink. The PN should respect the client's wishes and not force them to eat or drink.
Correct Answer is C
Explanation
Choice A reason: A child who has had a cold for two days and now is coughing up green sputum is not the most urgent client to assess. The child may have a bacterial infection that requires antibiotics, but the condition is not life-threatening or unstable. The child can be classified as urgent and seen within one hour.
Choice B reason: A male adolescent who has been vomiting for the past 12 hours and describes himself as very weak is not the most urgent client to assess. The adolescent may have dehydration, electrolyte imbalance, or gastroenteritis that requires fluid replacement and antiemetics, but the condition is not life-threatening or unstable. The adolescent can be classified as urgent and seen within one hour.
Choice C reason: A female client with severe right lower abdominal pain who is febrile and vomiting is the most urgent client to assess. The client may have appendicitis, ovarian torsion, ectopic pregnancy, or another serious condition that requires immediate diagnosis and treatment. The client is at risk of perforation, infection, shock, or hemorrhage and needs to be seen as soon as possible. The client can be classified as emergent and seen within 15 minutes.
Choice D reason: An elderly client with peripheral vascular disease who is complaining of severe leg pain when ambulating is not the most urgent client to assess. The client may have intermittent claudication, ischemia, or ulceration that requires analgesics, antiplatelets, or vascular surgery, but the condition is not life-threatening or unstable. The client can be classified as semi-urgent and seen within two hours.
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