A 10-year-old patient has returned to her room after a surgical procedure. Which observation should take priority for nursing action?
Absence of bowel sounds.
Pulse rate of 150 per minute.
Blood-tinged urine from the ureteral catheter.
Serosanguineous drainage on her incisional dressing.
The Correct Answer is B
Choice A rationale:
Absence of bowel sounds is not a priority in this situation as it is common for bowel sounds to be absent temporarily after surgery due to anesthesia and decreased peristalsis. It should be monitored, but it doesn't require immediate nursing action.
Choice B rationale:
A pulse rate of 150 per minute is a significant finding in a 10-year-old patient after surgery. Tachycardia can indicate pain, anxiety, hypovolemia, or other postoperative complications. Immediate nursing action is required to assess the cause and initiate appropriate interventions.
Choice C rationale:
Blood-tinged urine from the ureteral catheter might be expected after a surgical procedure involving the urinary system. While it requires monitoring, it is less urgent than addressing a high pulse rate in a postoperative child.
Choice D rationale:
Serosanguineous drainage on the incisional dressing is a normal finding in the immediate postoperative period. It indicates minor oozing of blood mixed with serous fluid. While it requires monitoring, it is not as concerning as the elevated pulse rate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Allowing the patient to stay in the chosen position might not be the best approach, as the child's preference might not align with therapeutic considerations for managing status asthmaticus.
Choice B rationale:
Semi-Fowler's position, with the head of the bed elevated, promotes improved lung expansion and easier breathing for patients with respiratory distress. Explaining the rationale behind this position to the child helps them understand its therapeutic benefits, encouraging compliance.
Choice C rationale:
Demonstrating various positions could confuse the child and delay appropriate intervention. A clear explanation of the preferred position is more effective in this critical situation.
Choice D rationale:
Removing pillows might be counterproductive, as elevating the head of the bed is beneficial for respiratory distress. This choice contradicts the therapeutic goal.
Correct Answer is D
Explanation
Choice A rationale:
Performing passive range-of-motion exercises could worsen the bleeding in a patient with hemarthrosis due to hemophilia. Immobilization minimizes movement, reducing the risk of bleeding.
Choice B rationale:
While oxygen administration might be indicated in certain situations, it's not the primary intervention for hemarthrosis. The focus should be on preventing further bleeding and complications.
Choice C rationale:
Elevating the head of the bed is generally recommended for improving oxygenation, but it's not the primary concern in managing hemarthrosis.
Choice D rationale:
Immobilizing the affected joint is crucial to prevent movement that could exacerbate bleeding. This approach is aimed at minimizing damage and controlling bleeding in a patient with hemophilia.
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