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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Abdominal pain rated 4 is moderate and should be managed but is not as immediately critical as hypotension.
B. A respiratory rate of 20/min is within normal limits for an adolescent and is not a priority finding.
C. Low blood pressure (hypotension) following blunt abdominal trauma is a concern for internal bleeding or hemorrhage. This is the priority finding and requires immediate intervention.
D. A heart rate of 72/min is normal and does not indicate immediate concern.
Correct Answer is B
Explanation
A. Typically, infants are kept NPO for 1-2 hours before a lumbar puncture, not 6 hours.
B. Holding the infant’s chin to the chest and knees to the abdomen during the lumbar puncture is the correct positioning. This position opens the intervertebral spaces and allows for easier access to the spinal cord.
C. Eutectic mixture of lidocaine and prilocaine (EMLA) cream should be applied 60 minutes before the procedure for effective local anesthesia, not 15 minutes.
D. After the procedure, the infant should be placed flat to avoid pressure on the lumbar area, not in an infant seat. The infant should be positioned on their back or side to prevent strain.
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