A nurse is collecting data from an adolescent client 24 hours after surgery. Which of the following findings should the nurse report to the primary health care provider?
Increased weight-bearing ability on the affected leg.
Warmth extending from the left calf to the knee.
Temperature of 38.8° C (101.8° F).
Itching in bilateral antecubital spaces.
The Correct Answer is C
Choice A rationale: Increased weight-bearing ability on the affected leg is typically an expected finding, especially as the client begins to recover postoperatively. Enhanced weight-bearing suggests improving strength, mobility, and healing in the affected limb. It does not usually indicate complications. As such, this finding does not necessitate reporting unless accompanied by other concerning symptoms, such as significant pain or changes in circulation.
Choice B rationale: Warmth extending from the left calf to the knee could indicate localized inflammation or infection. However, warmth alone is not definitive for conditions like deep vein thrombosis (DVT) or cellulitis. Without additional findings such as swelling, redness, or pain, it may not be immediately concerning. Nevertheless, it warrants monitoring as a precaution, particularly in postsurgical clients at risk for complications like DVT.
Choice C rationale: A temperature of 38.8° C (101.8° F) is above the normal range of 36.1° C to 37.2° C (97.0° F to 99.0° F) and suggests the possibility of a systemic infection, such as a postoperative wound infection. This finding is significant and must be reported promptly to the healthcare provider for further evaluation and intervention. Early detection and treatment of infections are crucial to prevent complications like sepsis.
Choice D rationale: Itching in bilateral antecubital spaces is a nonspecific symptom that may be attributed to a mild allergic reaction, irritation, or dryness of the skin. While it could indicate a reaction to medications or adhesives used during surgery, it is generally not an urgent concern unless accompanied by additional symptoms like rash, swelling, or respiratory distress. Close monitoring is recommended rather than immediate reporting.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale: Stridor during inspiration is a high-pitched, harsh sound caused by an upper airway obstruction. This is a critical finding that requires immediate attention, as it indicates compromised airflow potentially due to conditions like croup, epiglottitis, or foreign body aspiration. Left untreated, the obstruction can worsen, leading to severe hypoxia or respiratory failure. Prompt evaluation and intervention, such as securing the airway, are essential to ensure the child's safety and prevent life-threatening complications.
Choice B rationale: A wet, productive cough is typically associated with lower respiratory tract infections, such as bronchitis or pneumonia. While it warrants medical attention and treatment, it is not an immediate threat to the airway or oxygenation compared to stridor. Management often includes supportive care, hydration, and possibly antibiotics. However, this finding does not pose the acute risk that stridor represents in terms of respiratory distress and airway compromise.
Choice C rationale: A fever of 38.5°C (101.3°F) is a common finding in pediatric clients with infections. It indicates an inflammatory response to illness but is not immediately life-threatening. Fever management involves antipyretics, hydration, and monitoring for signs of more severe infection or sepsis. While elevated temperature requires attention, it does not carry the same urgency as stridor, which signals potential airway obstruction.
Choice D rationale: Irritability reported by the caregiver is a nonspecific symptom that may result from various causes, including pain, discomfort, or fever. While it suggests the child may be unwell, it does not directly indicate a critical condition or imminent danger. Monitoring and addressing the underlying cause of irritability are important, but this finding does not necessitate the same immediate response as stridor, which directly affects airway patency and oxygenation.
Correct Answer is A
Explanation
Choice A rationale
Allowing medications to flow by gravity ensures gradual administration, minimizing the risk of mucosal irritation and preventing excessive pressure or leakage in the nasogastric tube.
Choice B rationale
Crushing sustained-release tablets alters their pharmacokinetics, leading to uncontrolled drug release and increased risk of toxicity or subtherapeutic effects. Sustained-release formulations must remain intact.
Choice C rationale
Using 2 mL sterile water is inadequate for flushing a nasogastric tube post-medication; recommended flushing volumes typically range between 10-15 mL for effective clearance.
Choice D rationale
Mixing medications together may result in chemical interactions and altered bioavailability. Administering each medication individually is essential to maintaining integrity and therapeutic efficacy.
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.