Which patient finding indicates the need for further monitoring rather than discharge home after an outpatient surgical procedure?
Inability to void without fluid retention
Persistent nausea without vomiting
Lethargy that resolves after several hour
Pain management with opioid analgesics
The Correct Answer is A
A. Inability to void without fluid retention. Urinary retention is a common post-op complication, especially after anesthesia, and requires monitoring to prevent bladder distension or kidney issues.
B. Persistent nausea without vomiting. Nausea can be managed with antiemetics and does not necessarily require prolonged monitoring.
C. Lethargy that resolves after several hours. Post-anesthesia drowsiness is expected and does not necessarily indicate a need for extended observation.
D. Pain management with opioid analgesics. Pain control with opioids is expected and does not, by itself, require extended monitoring.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Circulating nurse: The circulating nurse ensures that the time-out occurs but does not mark the surgical site.
B. Patient's primary nurse: The primary nurse is responsible for preoperative care but does not mark the site.
C. Surgeon: The surgeon performing the procedure is responsible for marking the surgical site to ensure accuracy and prevent wrong-site surgery.
D. Surgical technician: Surgical technicians assist with instruments and procedures but do not mark the surgical site.
Correct Answer is D
Explanation
A. The client has a pleasant affect: "Affect" refers to outward emotional expression, whereas "mood" is the client's internal emotional state.
B. The client appears happy with an elevated mood: The nurse should document objective data rather than interpreting the client’s emotions.
C. The client self-isolated today: While self-isolation may indicate mood disturbances, it does not directly document the client’s reported mood.
D. The client rates their mood 4 out of 10: This entry reflects the client’s subjective report using a measurable scale, making it the most accurate documentation.
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