- A nurse is caring for a client who is postoperative.
Nurses' Notes
1400:
Client transferred from PACU following appendectomy. Oriented to person, place, and time. Surgical dressing is dry and intact. Wound drain has 30 mL of serosanguinous drainage. Client reports pain is 7 on a scale of 0 to 10.
2200
Bowel sounds are present in all quadrants. Client is passing flatus. Urinary output is 400 mL over 6 hr. Client reports incisional pain of 4 on a scale of 0 to 10. Surgical dressing has a moderate amount of serosanguinous drainage. Wound drain has 0 mL output over 8 hr.
Vital Signs
1400:
Temperature 37.8° C (100" F)
Heart rate 110/min
Respiratory rate 18/min
Blood pressure 165/70 mmHg
SpO2 95% on room air
1800:
Temperature 37.8° C (100° F)
Heart rate 96/min
Respiratory rate 20/min
Blood pressure 125/78 mmHg
SpO2 96% on room air
Provider Prescriptions
1400
Ceftriaxone 1 gram IV daily
Acetaminophen 650 mg PO every 6 hours for pain
Which of the following should the nurse request as a recommendation in an SBAR report to the provider? Select All That Apply
Medication for elevated temperature
Insertion of NG tube for decompression
Oxygen 2 to 4 L/min via nasal cannula
Insertion of urinary catheter
Evaluation of surgical wound drain
Correct Answer : A,E
Rationale:
A. While the client's temperature is not extremely high, it is elevated and persistent. Requesting an antipyretic or further evaluation may be warranted to prevent potential complications.
B. Insertion of NG tube for decompression is not necessary as the client is passing flatus and has bowel sounds in all quadrants, indicating normal gastrointestinal function.
C. Oxygen 2 to 4 L/min via nasal cannula is not necessary since the client's SpO2 levels are within normal range on room air.
D. The client's urinary output is adequate (400 mL over 6 hours), so a catheter is not required at this time.
E. The lack of drainage from the wound drain could indicate a problem that requires immediate attention. This could prevent complications like infection or fluid accumulation.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is ["A","D"]
Explanation
Rationale:
A. Ambulate an older adult client who has hypertension is a task that an AP can perform, provided the client is stable and has been assessed by the nurse.
B. Provide discharge instructions for a client who has a new skin graft is a task that requires nursing judgment and cannot be delegated to an AP.
C. Check a blood product with another nurse prior to administration is a nursing responsibility that requires verification by licensed personnel and cannot be delegated to an AP.
D. Weigh a client who has heart failure is appropriate for an AP, as it involves routine measurement that can be delegated.
E. Perform an admission assessment on a client is a nursing responsibility and cannot be delegated to an AP.
Correct Answer is D
Explanation
Rationale:
A. Insisting the client take medications does not respect the client’s autonomy and is not an advocacy action.
B. Informing the client that the medication is the same as taken at home does not necessarily address the client’s concerns or questions.
C. Telling the client that refusal is noncompliance does not support client autonomy and does not address their concerns.
D. Encouraging the client to verbalize questions supports their right to be informed and make decisions about their care, demonstrating advocacy.