Questions 63

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Extract:

Nurses’ Notes
1930 – Assessment completed

Peripheral pulses were all palpable. S1/S2 heart tones auscultated. No peripheral edema.

Lung sounds were clear in all fields. Client denied any cough or dyspnea. Respirations were regular and unlabored.

Bowel sounds were active in all quadrants, with no abdominal distention noted. Client only reports nausea after her prescribed acetaminophen-oxycodone.

Surgical incisions appeared approximated, reddened, and the surrounding area was hot to touch. Small amount of foul-smelling, purulent type of drainage was noted. The gauze dressing was changed, and a new gauze dressing was applied.

Client reported intermittent incisional pain of 3/10 described as ‘sore’. Vital Signs: Oral Temperature 100.4° F (38° C)

Pulse 93/minute

Respirations 18/minute

Blood pressure 111/69 mm Hg

O2 saturation 95% on room air


Question 1 of 5

The nurse performs a physical assessment for a client three days post-operative following a radical hysterectomy.Select three (3) assessment and vital sign findings that are highly concerning.

Correct Answer: D,F,G

Rationale: This client is demonstrating signs and symptoms of a surgical site infection. The findings requiring follow-up include the foul-smelling drainage that is purulent. Further, this client also has a concern for their oral temperature as it is a clinical fever.

Findings that are not highly concerning include the client’s incisional pain which is described as sore and is intermittent. This is an expected finding following surgery. The wounds being approximated is an optimal finding. The client’s pulse is within normal limits. Finally, nausea after pain medication is a common side-effect.

Extract:


Question 2 of 5

Correct Answer:

Rationale:

Question 3 of 5

Correct Answer:

Rationale:

Question 4 of 5

Correct Answer:

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Question 5 of 5

Correct Answer:

Rationale:

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