Examkin

Soru

Zorluk: OrtaReduction of Risk Potential

A practical nurse (PN) is collecting data on a client 12 hours after a total abdominal hysterectomy. Which of the following assessment findings are considered expected, benign post-operative findings that can be safely documented without immediate escalation to the registered nurse (RN)? Select all that apply.

  1. Scant serosanguineous drainage on the surgical dressing that has remained unchanged for 4 hours.Cevap
  2. B
    A resting heart rate of 118 bpm and a blood pressure of 94/62 mm Hg.
  3. Hypoactive bowel sounds auscultated in all four abdominal quadrants.Cevap
  4. D
    A morning laboratory report showing a hemoglobin level of 7.6 g/dL.
  5. A reported incisional pain level of 3 on a 0 to 10 scale one hour after receiving an oral analgesic.Cevap
  6. F
    Sudden-onset shortness of breath and an oxygen saturation of 89% on room air.

Cevap

The expected, benign findings are scant serosanguineous drainage on the dressing, hypoactive bowel sounds, and a controlled pain level of 3 out of 10.
In the early post-operative period (12 hours) following abdominal surgery, it is entirely expected for bowel motility to be slow (hypoactive bowel sounds), for minor, non-expanding serosanguineous drainage to be present on the dressing, and for pain to be present but manageable (3/10) with prescribed analgesics. These findings indicate a normal recovery trajectory.

Adım Adım Çözüm

1
Analyze the client's post-operative timeline and surgical procedure.
The client is 12 hours post-total abdominal hysterectomy, a major abdominal surgery.
Establishing the timeline helps differentiate between normal early healing processes and emerging acute complications.
2
Evaluate each assessment finding against expected post-operative physiological responses.
Identified that scant drainage, sluggish bowel sounds, and mild pain are normal. Conversely, hypoxia, abnormal vital signs, and low hemoglobin are abnormal.
The PN must use clinical judgment to discriminate between findings that require basic monitoring versus those demanding immediate RN escalation.
3
Select the findings that represent benign conditions.
The scant serosanguineous drainage, hypoactive bowel sounds, and well-controlled pain level are selected.
These findings fulfill the prompt's requirement to identify safe, expected data that do not warrant urgent intervention.

Anahtar Kavram

Discriminating between expected post-operative findings and signs of emergent complications (e.g., shock, hemorrhage) to reduce client risk.
Tahmini Süre:1m 30s
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Konular

Reduction of Risk Potential

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