PN Adult Medical Surgical Practice Exam

Which postoperative finding requires immediate attention from the nurse?

1. Reported pain level of 6 on a scale of 0 to 10.

2. Urinary output of 110 mL in the past 4 hours.

3. Temperature of 38º C (100.4º F).

4. Oxygen saturation of 88%.

The correct answer is: Oxygen saturation of 88%.

An oxygen saturation level of 88% is a finding that requires immediate attention from the nurse. Normal oxygen saturation levels typically range from 95% to 100%. When a patient's oxygen saturation falls significantly below this range, it indicates that the patient may not be receiving enough oxygen to meet their body's needs, leading to potential hypoxia. This situation can cause serious complications, especially in a postoperative setting where the patient's respiratory function may be compromised due to anesthesia, pain, or other factors. Immediate intervention is necessary to address this low oxygen saturation, which may involve administering supplemental oxygen, repositioning the patient to improve lung expansion, or conducting further assessments to determine the cause of respiratory distress. Timely action can help prevent deterioration of the patient's condition and ensure better outcomes post-surgery. In contrast, the other options, while they may indicate discomfort or require monitoring, do not generally warrant the same level of urgency as an oxygen saturation of 88%. For instance, a pain level of 6 is concerning, but it can typically be managed with analgesics. Similarly, a urinary output of 110 mL over 4 hours falls within the range that may be acceptable following surgery, although it should be monitored. A temperature of 38º C (