A nurse is assessing a school-age child immediately postoperative following a perforated appendix. Which of the following finding should the nurse expect?

A WBC of 6,000/mm3

Purulent nasogastric drainage

Passage of dark red stool with mucus

Absence of peristalsis

Answer and Explanation

The Correct Answer is D

A. A WBC of 6,000/mm³ is within the normal range (4,500-11,000/mm³), and a postoperative infection is more likely to result in an elevated WBC count.

B. Purulent nasogastric drainage is more suggestive of a gastrointestinal issue unrelated to a perforated appendix and is not a common finding post-surgery.

C. Passage of dark red stool with mucus could suggest gastrointestinal bleeding or infection, but it is not typical postoperatively after a perforated appendix.

D. After surgery for a perforated appendix, peristalsis may be absent initially due to the effects of anesthesia, bowel manipulation, or inflammation from the infection. This is a normal postoperative finding.

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Correct Answer is B

Explanation

A. Elevating the head of the bed may be useful after airway management but is not the priority in anaphylaxis.

B. Administering IM epinephrine is the priority action in anaphylaxis, as it works rapidly to reverse the symptoms by constricting blood vessels, relaxing smooth muscles, and improving breathing.

C. Determining the allergen is important for future prevention, but the immediate priority is treating the reaction.

D. While establishing IV access is important for fluid resuscitation, it is not the priority over administering epinephrine in anaphylaxis.

A. Urticaria B. Fatigue C. Anorexia D. Vomiting

Correct Answer is A

Explanation

A. Urticaria (hives) could indicate an allergic reaction or hypersensitivity to the chemotherapy, which needs to be addressed immediately to prevent more severe reactions, such as anaphylaxis.

B. Fatigue is a common side effect of chemotherapy and not usually an immediate concern unless accompanied by signs of more serious complications.

C. Anorexia can occur during chemotherapy but is typically managed with dietary adjustments and does not usually require urgent attention unless it leads to dehydration or significant weight loss.

D. Vomiting is a common side effect of chemotherapy, but it is usually managed with antiemetic medication and is not as immediately concerning as an allergic reaction.

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A nurse is assessing a school-age child immediately postoperative following a perforated appendix. Which of the following finding should the nurse expect?

Nursing Test Bank

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