When entering the room of a sedated postoperative client, which assessment requires immediate intervention by the nurse?

Low intermittent suction prescribed for the nasogastric tube is turned off.

A Hemovac drain is partially full of serous drainage and is not compressed.

The urinary catheter drainage bag is almost completely full of amber urine.

Oxygen is being administered via nasal cannula at 4 L/minute without humidification.

Answer and Explanation

The Correct Answer is D

A. This requires prompt attention but is not immediately life-threatening.

B.   This requires attention but does not pose an immediate threat to the client's condition.

C.   An almost completely full urinary catheter drainage bag requires attention but does not pose an immediate threat to the client's condition.
D.   Administering oxygen without humidification could lead to mucosal dryness and damage, and should be addressed promptly.

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Correct Answer is B

Explanation

A. While the length of exposure can be relevant, it is not the most critical factor before starting isoniazid.
B. Isoniazid can cause hepatotoxicity, so a current diagnosis of hepatitis B is crucial to note as it increases the risk of liver damage.
C. A history of intravenous drug abuse is important for overall health assessment but is less critical than current liver disease.
D. Conversion of the PPD test indicates TB exposure, but assessing liver function and potential for hepatotoxicity is more urgent before starting the medication.

A. Heart rate 121 beats/minute B. Capillary refill 2 seconds C. Respirations 28 breaths/minute with shallow breathing D. Radial and pedal pulses 2+ E. Severe abdominal pain in right lower quadrant F. Feels anxious G. Temperature 100.8° F (38.2° C) H. Vomiting small amounts of green bile I. Blood pressure 115/76 mm Hg

Correct Answer is ["A","C","E","G","H"]

Explanation

A. Tachycardia indicates the body is responding to pain, infection, or potential sepsis. It's a critical vital sign indicating the body's stress response.
B. Tachypnea can be a response to pain or anxiety but also indicates the need for careful monitoring of respiratory status, especially postoperatively.

C. A capillary refill of 2 seconds is within the normal range and indicates adequate peripheral perfusion.
D. Radial and pedal pulses 2+ are within the normal range and indicates adequate peripheral perfusion.
E. Severe abdominal pain in the right lower quadrant is a primary symptom of appendicitis, which is confirmed by the CT scan showing a dilated appendix and fat stranding. Immediate attention is needed to address potential complications such as rupture.
F. Feeling anxious needs to be managed to promote patient comfort. However, it doesn’t need to be managed immediately since it is not life-threatening.
G. Fever is a sign of infection or inflammation, common in appendicitis. Monitoring and managing fever is crucial in preventing further complications.
H. Bilious vomitus is a common finding in appendicitis and may indicate that the inflammation has progressed to a point where it is causing a blockage in the intestines. This obstruction can lead to increased pressure within the abdominal cavity and compromise blood flow, potentially resulting in a life-threatening situation.
I. A blood pressure of 115/76 mm Hg is within normal limits and indicates stable hemodynamics at this point.

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When entering the room of a sedated postoperative client, which assessment requires immediate intervention by the nurse?

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Naxlex Comprehensive Predictor Exams

A client exposed to tuberculosis is scheduled to begin prophylactic treatment with isoniazid. Which information is most important for the nurse to note before administering the initial dose?

Correct Answer is B

Explanation

Exhibits The nurse is caring for the client. Which of the following assessment findings should the nurse prioritize?

Correct Answer is ["A","C","E","G","H"]

Explanation

The nurse observes a client prepare a meal in the kitchen of a rehabilitation facility prior to discharge. What behavior(s) indicate the client understands how to maintain balance safely? Select all that apply.

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