A nurse is caring for a patient who is one day postoperative following an appendectomy. What findings should the nurse report?
Hypoactive bowel sounds in all four quadrants.
Red streaks along the incision.
Serosanguineous drainage at the incision site.
Temperature 37.2 C (99 F).
The Correct Answer is B
Choice A rationale
Hypoactive bowel sounds in all four quadrants are not unusual in a patient one day postoperative following an appendectomy. This is because anesthesia and surgery can slow down the bowel movements temporarily.
Choice B rationale
Red streaks along the incision are a sign of infection. This could indicate cellulitis, a common skin infection that can be serious if left untreated. The red streaks are often warm to the touch and may be accompanied by other signs of infection such as fever, pain, and swelling.
Therefore, the nurse should report this finding.
Choice C rationale
Serosanguineous drainage at the incision site is not uncommon in the first few days after surgery. It is a mixture of blood and serum and is usually light pink to blood-tinged in color. However, if the drainage is heavy, or if it continues for more than a few days, it could be a sign of a problem such as infection or poor wound healing.
Choice D rationale
A temperature of 37.2 C (99 F) is within the normal range for body temperature. A slight elevation in temperature can be expected after surgery due to the body’s inflammatory response to the surgical trauma.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
The statement “Stop taking the medication if you feel drowsy” is incorrect. Drowsiness is not a common side effect of levothyroxine, and stopping the medication abruptly can lead to withdrawal symptoms and a rebound of hypothyroid symptoms.
Choice B rationale
The statement “Expect to take this medication for 4 to 6 weeks” is incorrect. Levothyroxine is typically a lifelong therapy for individuals with hypothyroidism, not a short-term treatment.
Choice C rationale
The statement “This medication may cause permanent hair loss” is incorrect. While hair loss can be a side effect of levothyroxine, it is usually temporary and resolves as the body adjusts to the medication.
Choice D rationale
Weighing oneself at the same time every day is a good practice when taking levothyroxine. This can help monitor for changes in weight, which could indicate that the dose of levothyroxine needs adjustment.
Correct Answer is B
Explanation
Choice A rationale
Encouraging fluids with meals is not the best choice for a client who has HIV. While hydration is important, drinking fluids with meals can fill the stomach and decrease the client’s appetite, potentially leading to inadequate nutrient intake.
Choice B rationale
Offering small, frequent meals is a recommended intervention for a client who has HIV. This approach can help to maximize nutrient intake and manage symptoms such as nausea and early satiety. This is the correct choice.
Choice C rationale
While fresh fruits and vegetables are generally part of a healthy diet, they may not be appropriate for all clients with HIV. Some individuals may have difficulty digesting these foods, and others may be at risk of infection from uncooked produce.
Choice D rationale
Providing a diet of pureed foods is not a standard intervention for clients with HIV. This approach may be necessary for individuals with certain conditions or symptoms, but it is not applicable to all clients with HIV23.
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