The practical nurse (PN) is evaluating a client who is admitted to the hospital with a diagnosis of cholelithiasis. Which finding should the practical nurse (PN) report to the charge nurse?

Choice A reason: Evaluating the return of the gag reflex is important for assessing a client's ability to protect their airway and for readiness to eat or drink after surgery. However, it is not the immediate priority when a client is repeatedly swallowing, which can indicate bleeding.
Choice B reason: Demonstrating relaxation techniques can be beneficial for managing pain and anxiety, but it does not address the immediate concern of potential postoperative bleeding in a client who is repeatedly swallowing.
Choice C reason: Using a penlight to assess the pharynx for bleeding is the priority action. Repeated swallowing after rhinoplasty can indicate bleeding, and assessing the pharynx allows the nurse to identify and address any postoperative hemorrhage promptly.
Choice D reason: Administering an intravenous analgesic per PRN protocol may help manage pain, but it is not the priority action. The primary concern is to check for potential bleeding, which is indicated by the repeated swallowing.

Choice A reason: A respiratory rate of 28 breaths per minute indicates tachypnea, which can be a response to pain, anxiety, or hypovolemia. While it is important to monitor and manage respiratory status, this finding alone is not as critical as urine output when assessing the client's overall condition and fluid balance. Tachypnea should be reported, but it is not the most urgent parameter in this scenario.
Choice B reason: A blood pressure of 110/90 mm Hg is within a range that might be acceptable for some individuals, though the pulse pressure is narrow. In the context of a client receiving blood and fluid replacement, it is important to monitor blood pressure closely to ensure adequate perfusion. However, this reading does not immediately suggest a severe complication or shock, and other parameters might take precedence for immediate reporting.
Choice C reason: Urine output of 20 mL in the last hour is significantly low, indicating potential renal hypoperfusion or early signs of shock. Adequate urine output is a crucial indicator of renal perfusion and overall fluid status. Oliguria (reduced urine output) in this context suggests that the client's organs may not be receiving sufficient blood flow, which is a critical condition that requires prompt intervention. This finding should be reported immediately to the charge nurse to ensure timely and appropriate management.
Choice D reason: A pain score of 8 out of 10 indicates severe pain, which needs to be managed effectively to ensure the client's comfort and prevent further physiological stress. While addressing pain is important, it does not directly indicate a life-threatening condition compared to low urine output. Pain management should be part of the overall care plan, but reporting the critically low urine output takes priority in this situation.