A nurse is caring for an adolescent who is 1 hr postoperative following an appendectomy.
Which of the following findings should the nurse report to the provider?
Abdominal pain.
Muscle rigidity.
Temperature 36.4° C (97.5° F)
Heart rate 63/min.
The Correct Answer is A
Choice A rationale:
Abdominal pain in a postoperative patient, especially after an appendectomy, is concerning and should be reported to the provider immediately. It could indicate complications such as infection, ileus, or surgical site issues. Prompt reporting and assessment are crucial to prevent further complications and ensure the patient's well-being.
Choice B rationale:
Muscle rigidity is not a typical finding 1 hour postoperative following an appendectomy. While muscle rigidity can be a sign of various conditions, it is not a common immediate concern after this type of surgery, especially in the early postoperative period.
Choice C rationale:
A temperature of 36.4°C (97.5°F) is within the normal range for body temperature. While it's important to monitor the patient's temperature for signs of infection, this temperature alone is not a cause for immediate concern.
Choice D rationale:
A heart rate of 63/min is within the normal range for an adolescent at rest. Heart rate can vary based on factors such as age, activity level, and overall health. A heart rate of 63/min does not indicate an immediate problem and is not a cause for immediate concern in this context.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale:
Increased heart rate is not a direct indication of the effectiveness of chest physiotherapy treatments in a child with cystic fibrosis. The primary goal of chest physiotherapy is to clear mucus from the airways and improve breathing.
Choice B rationale:
Increased urine output is not directly related to the effectiveness of chest physiotherapy treatments. The focus of chest physiotherapy is on respiratory function and mucus clearance.
Choice C rationale:
Increased expectoration (coughing up mucus) is a positive sign that chest physiotherapy treatments have been effective. Improved clearance of mucus from the airways helps in breathing and reduces the risk of respiratory infections. It indicates that the treatments are helping the child clear the mucus, which is a common problem in cystic fibrosis.
Choice D rationale:
Reduced pain is not the primary goal of chest physiotherapy treatments for cystic fibrosis. While it's essential for the child to be comfortable, the main focus is on improving respiratory function and clearing mucus from the airways.
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale: Lime-flavored ice pops are cold and soothing, which helps reduce throat pain and swelling post-tonsillectomy. They also provide hydration and are less likely to irritate the surgical site compared to dairy products.
Choice B rationale: Sugar-free cherry gelatin, while hydrating and easy to swallow, may not be recommended immediately post-tonsillectomy. The red dye can be confused with blood if the child vomits, making it harder to assess post-surgical complications.
Choice C rationale: Vanilla ice cream contains dairy, which can increase mucus production and cause throat irritation, potentially making it uncomfortable for a child post-tonsillectomy. It's better to avoid dairy products initially to prevent such issues.
Choice D rationale: Chocolate milk, like vanilla ice cream, contains dairy that can increase mucus production. Additionally, the chocolate can be irritating to a healing throat. Cold, clear, non-dairy fluids are preferable initially post-tonsillectomy for comfort and safety.
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