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
Avoiding administration of the influenza vaccine is not a recommended intervention for a patient experiencing sickle cell crises. Vaccinations are important for patients with sickle cell disease to prevent infections that can trigger crises.
Choice B rationale
Providing a diet that is low in protein is not a recommended intervention for a patient experiencing sickle cell crises. Patients with sickle cell disease need a balanced diet that includes adequate protein to support tissue repair and growth.
Choice C rationale
Decreasing fluid intake to 1,500 mL daily is not a recommended intervention for a patient experiencing sickle cell crises. Adequate hydration is important to prevent sickling of cells and to maintain blood volume.
Choice D rationale
Maintaining the patient on bed rest is the correct intervention. Rest can help to decrease the body’s demand for oxygen, reduce stress on the body, and prevent complications such as acute chest syndrome.
Correct Answer is ["B","D"]
Explanation
Choice A rationale
Scheduled times for dressing changes are not typically included in transfer documentation. This information is usually part of the patient’s daily care plan and can be communicated to the receiving unit as needed.
Choice B rationale
The primary health problem is crucial information to include in the transfer documentation. It provides the receiving unit with a clear understanding of the patient’s main health issue and the reason for their transfer.
Choice C rationale
Admission vital signs from 1 week ago are not typically included in transfer documentation. The most recent vital signs are more relevant and provide a better indication of the patient’s current health status.
Choice D rationale
Current medication prescriptions are essential to include in the transfer documentation. This information ensures continuity of care and prevents medication errors.
Choice E rationale
The number of family members who have visited is not typically included in transfer documentation. This information is not directly related to the patient’s health status or care needs.
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