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 A
Explanation
Choice A rationale:
Stomatitis, inflammation of the oral mucosa, can make eating painful, leading to inadequate nutritional intake. The discomfort caused by stomatitis can discourage the patient from eating, potentially resulting in malnutrition. Ensuring adequate nutritional intake is crucial to support the patient's immune system and healing during antineoplastic therapy.
Choice B rationale:
Dental caries are not directly related to stomatitis. Stomatitis is inflammation of the oral mucosa, whereas dental caries involve decay of tooth structure due to bacterial action on food debris and sugars.
Choice C rationale:
Diarrhea is unrelated to stomatitis. Diarrhea involves frequent, loose, or watery stools, often caused by gastrointestinal infections, certain medications, or dietary intolerances.
Choice D rationale:
Gingival hyperplasia is an overgrowth of gum tissue and is not a likely result of stomatitis. It can be associated with some medications like anticonvulsants.
Correct Answer is D
Explanation
Choice A rationale:
Maintaining supplemental oxygen is not directly relevant to the management of hemarthrosis in a patient with hemophilia. Hemarthrosis is bleeding into a joint due to impaired clotting factors in hemophilia, and oxygen supplementation is not a primary intervention.
Choice B rationale:
Elevating the head of the bed 45 degrees is not the most appropriate action for hemarthrosis. Elevation would not address the joint bleeding, and it could potentially cause discomfort to the patient.
Choice C rationale:
Providing passive range-of-motion exercises to all extremities is contraindicated in this scenario. Active or passive range-of-motion exercises could exacerbate bleeding and further damage the affected joint in a patient with hemarthrosis.
Choice D rationale:
Immobilizing the affected joint is the correct nursing action. Immobilization helps to prevent further bleeding and joint damage. By limiting movement, the risk of exacerbating the bleeding is minimized, promoting healing and reducing pain.
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