Question

A client asks why a drain is in place to pull fluid from the surgical wound. What is the best response by the nurse?

• “It assists in preventing infection.” 

Question

A client develops a hemorrhage one-hour post-surgery. The nurse knows this is most likely an intermediary hemorrhage from a vein because it occurred:

• within the first few hours and has darkly colored blood that bubbles out slowly.

Question

A client had a nephrectomy 2 days ago and is now complaining of abdominal pressure and nausea. The first nursing action should be to:

• auscultate bowel sounds.

Question

A client is at postoperative day 1 after abdominal surgery. The client is receiving 0.9% normal saline at 75 mL/h, has a nasogastric tube to low wall suction with 200 mL every 8 hours of light yellow fluid, and a wound drain with 50 mL of dark red drainage every 8 hours. The 24-hour urine output total is 2430 mL. What action by the nurse is most appropriate?

• Assess for signs and symptoms of fluid volume deficit.

Question

A client is at postoperative hour 8 after an appendectomy and is anxious, stating “Something is not right. My pain is worse than ever and my stomach is swollen.” Blood pressure is 88/50, pulse is 115, and respirations are 24 and labored. The abdomen is soft and distended. No obvious bleeding is noted. What action by the nurse is most appropriate?

• Notify the physician.

Question

A client is postoperative day 3 after surgical repair of an open abdominal wound and traumatic amputation of the right lower leg following a motorcycle crash. What is the highest priority nursing intervention?

• Assessing WBC count, temperature, and wound appearance

Question