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 A
Explanation
A sigmoidoscopy is a procedure used to examine the lower part of the colon (sigmoid colon and rectum). The knee-chest position allows for better visualization of the sigmoid colon by straightening the rectosigmoid junction.
Choice B rationale
The prone position is not typically used for sigmoidoscopy. This position does not provide optimal visualization of the sigmoid colon.
Choice C rationale
The orthopneic position, which involves sitting up and leaning forward, is not used for sigmoidoscopy.
Choice D rationale
The Trendelenburg position, which involves lying flat with the feet elevated higher than the head, is not used for sigmoidoscopy.
Correct Answer is C
Explanation
Elevating the legs on pillows when in bed is not typically recommended for patients with peripheral arterial disease (PAD). This position can actually decrease arterial blood flow to the legs and worsen symptoms.
Choice B rationale
Applying a heating pad for 15 minutes twice per day is not a standard recommendation for managing PAD. While heat can increase blood flow, it can also lead to burns in patients with decreased sensation due to PAD1.
Choice C rationale
Beginning an exercise program that includes walking is often recommended for patients with PAD. Regular physical activity can improve symptoms of claudication (pain caused by reduced blood flow) and increase overall cardiovascular health.
Choice D rationale
Wearing knee-high support hose during the day is not typically recommended for patients with PAD. Compression stockings are more often used in the management of venous rather than arterial conditions.
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