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 ["A","D","E"]
Explanation
Choice A rationale: Offering the infant a pacifier during feedings can help with non-nutritive sucking, which is beneficial for the development of oral motor skills. It can also provide comfort and a sense of normalcy for the infant during tube feedings. This practice is encouraged to promote positive feeding experiences and support the infant's overall development.
Choice B rationale: Placing the infant in a supine position during feedings is not recommended due to the increased risk of aspiration. The preferred position is to keep the infant in an upright or semi-upright position to facilitate proper digestion and reduce the risk of gastroesophageal reflux and aspiration. Proper positioning is crucial for the safety and well-being of the infant during enteral feedings.
Choice C rationale: Heating the formula to 39°C (102°F) is not advised as it can be too hot and cause burns or discomfort to the infant. The formula should be administered at room temperature or slightly warmed to body temperature to ensure it is safe and comfortable for the infant. Proper temperature regulation is important to prevent thermal injuries.
Choice D rationale: Checking for residual volumes by aspirating stomach contents is an important step in assessing the infant's tolerance to the feeding. It helps determine if the previous feeding has been adequately digested and can indicate potential issues such as delayed gastric emptying. Regular assessment of residual volumes is a standard practice in managing enteral feedings for infants.
Choice E rationale: Instilling the formula over a period of 30 to 45 minutes is recommended to mimic normal feeding patterns and promote proper digestion. Slow and controlled administration of the feeding reduces the risk of gastrointestinal discomfort and aspiration. It also allows for better tolerance and absorption of the nutrients in the formula.
Correct Answer is D
Explanation
Choice A rationale:
Teaching the child about cast care is essential, but it is not the first priority. The immediate concern is addressing the child's comfort and preventing complications associated with the fractured right tibia. Teaching can come after addressing the acute needs.
Choice B rationale:
Petaling the edges of the cast might be necessary to prevent skin irritation, but it is not the first action to take. Elevating the child's leg is crucial to reduce swelling and promote blood circulation, which is the priority in this situation.
Choice C rationale:
Administering pain medication is important for the child's comfort, but it should not be the first action. Elevating the leg helps in reducing pain and swelling and promotes overall healing.
Choice D rationale:
Elevating the child's leg is the first action the nurse should take. Elevating the leg above heart level helps reduce swelling and improves blood circulation, which is crucial in the initial phase after applying the cast. This action can help prevent complications and promote the healing process. Once the leg is elevated, the nurse can then proceed with teaching the child about cast care and administering pain medication if needed.
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