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:
Inflammation and edema of the scrotum is not a typical symptom of gonorrhea. Scrotal involvement is more commonly associated with conditions like epididymitis.
Choice B rationale:
Painful urination with yellow urethral discharge is a classic symptom of gonorrhea. The infection affects the genitourinary tract, causing discomfort during urination and a characteristic purulent discharge.
Choice C rationale:
Maculopapular rash in the genital area is not a typical presentation of gonorrhea. This type of rash might be seen in other infections, such as syphilis.
Choice D rationale:
Red, hard lesion on the penis is not a common manifestation of gonorrhea. This description more closely matches the appearance of a primary syphilis chancre.
Correct Answer is B
Explanation
Choice A rationale:
Administering pancreatic enzymes between meals may not provide the necessary digestive support when food is introduced to the gastrointestinal tract. These enzymes are meant to aid in digestion, so administering them between meals might not be as effective as when taken in conjunction with food.
Choice B rationale:
Administering pancreatic enzymes before meals is the most appropriate time because it helps replace the missing enzymes in patients with cystic fibrosis. These enzymes aid in breaking down food and absorbing nutrients, compensating for the deficient pancreatic function. By giving the enzymes before meals, the body has the necessary support to digest the incoming food.
Choice C rationale:
While administering enzymes during meals might seem logical, it's actually less effective. The enzymes need time to mix with the ingested food before it enters the small intestine, where digestion primarily occurs.
Choice D rationale:
Administering pancreatic enzymes after meals wouldn't be as effective because the enzymes need to be present when food enters the stomach and begins the digestive process.
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