NCLEX Questions-Perioperative Nursing Care

The nurse has just reassessed the condition of a postoperative client who was admitted 1 hour ago to the surgical unit. The nurse plans to monitor which parameter most carefully during the next hour? 1. Urinary output of 20 ml/hour 2. Temperature of 37.6C (99.6F) 3. Blood pressure of 100/70 mm Hg 4. Serous drainage on the surgical dressing 1. Rationale-Urine output should be maintained at a minimum of 30 mL/hour for an adult. An output of less than 30mL for each of 2 consecutive hours should be reported to the health care provider. A temperature higher that 37.7C (100F) or lower than 36.1C (97F) and a falling systolic blood pressure lower than 90 mm Hg, are usually considered reportable immediately. The client's preoperative or baseline blood pressure is used to make informed postoperative comparisons. Moderatae or light serous drainage from the surgical site is considered normal.