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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Abdominal rigidity in a client with a bowel obstruction due to a volvulus indicates possible peritonitis, which is a medical emergency.
B. Paralytic ileus with absent bowel sounds is concerning but not immediately life- threatening.
C. A nasogastric tube draining greenish fluid is expected in small bowel obstruction.
D. Abdominal distention in large intestine obstruction is concerning but less urgent than potential peritonitis.
Correct Answer is D
Explanation
A. Background music may be distracting rather than helpful during teaching.
B. Adequate lighting is crucial for older adults to clearly see and read instructional materials. However, overhead lights may be distracting and disorienting for an older adult.
C. Standing behind the client might actually increase feelings of intimidation or discomfort. It's better to face the client to facilitate communication.
D. Providing handouts written at a 12th grade reading level ensures that the information is accessible and understandable for the majority of adults.
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