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 D
Explanation
The correct answer is choice d. Demonstrate deep-breathing and counting exercises.
Choice A rationale:
Using vague language to describe the procedure can increase anxiety and fear in the child. Clear and age-appropriate explanations help the child understand what to expect.
Choice B rationale:
A 30-minute teaching session may be too long for a school-age child, leading to loss of attention and increased anxiety. Short, focused sessions are more effective.
Choice C rationale:
Explaining the procedure in the playroom can associate a place of comfort with stress and anxiety. It’s better to explain the procedure in a neutral or medical setting.
Choice D rationale:
Demonstrating deep-breathing and counting exercises helps the child manage anxiety and pain during the procedure. These techniques are effective coping strategies for children undergoing medical procedures.
Correct Answer is ["C","D","F"]
Explanation
Choice A rationale:
The sleeping pattern is mentioned, but it does not provide relevant information regarding the infant's condition. The fact that the infant is sleeping through the night does not address the concerns related to gastroesophageal reflux.
Choice B rationale:
Irritability is mentioned in the notes, but it is not a parameter that directly reflects the improvement or worsening of the infant's condition. While irritability can be a symptom of discomfort due to reflux, it's not a parameter to monitor progress over time.
Choice C rationale:
Monitoring the infant's weight is crucial in this scenario. Weight gain is a significant indicator of the infant's overall health and nutritional status. A decrease in weight gain could indicate feeding difficulties or other health issues. In this case, the weight has increased, suggesting improvement in the infant's condition.
Choice D rationale:
Regurgitation is one of the main symptoms of gastroesophageal reflux. Monitoring the frequency and severity of regurgitation is essential to assess the effectiveness of interventions, such as thickened feedings. The persistence of regurgitation in this case indicates that the condition has not completely resolved.
Choice E rationale:
Heart rate is not mentioned in the provided information, and it does not provide relevant information about the infant's condition in this context.
Choice F rationale:
Bottle feeding is mentioned, specifically the thickening of feedings. This information is crucial in assessing the effectiveness of interventions for gastroesophageal reflux. Thickened feedings are often recommended to reduce regurgitation, and the fact that the parents have been thickening the feedings suggests an attempt to manage the condition.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.