NCLEX-PN

Category - Reduction of Risk

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A surgical floor nurse reports which assessment finding first to the physician?

Pain upon dorsiflexion of the foot
Post-operative incision pain, 8/10
Negative bowel sounds, no flatus is noted
Urine output of 30 cc from 6am-7am

Explanation

Answer: A - Pain during dorsiflexion of the foot demonstrates Homan’s sign, an indicator of thrombophlebitis. Option B is an expected outcome during the post-operative period. Option C may occur during the first few days post-operatively. Urine output of 30cc per hour is normal.

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