Basic Care and Comfort NCLEX PN Questions Nursing Practice Question
The nurse is assessing the client who was just admitted to a surgical unit following abdominal surgery. Which assessment finding requires immediate intervention by the nurse?
Correct Answer: D
Rationale: Assessment of post-surgical patients is critical for identifying complications. A Jackson-Pratt drain with 30 mL of serosanguineous drainage indicates potential bleeding or serous fluid accumulation, necessitating immediate intervention to prevent further complications.
Option A, dark bloody returns from a nasogastric tube, may warrant monitoring but can be expected post-surgery. Option B's oxygen saturation of 92% is low but manageable with supplemental oxygen. Option C's small amount of drainage is concerning but typically does not require urgent action unless it increases significantly. Thus, option D represents the most immediate risk.