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 C
Explanation
Choice A rationale
Daily weights are primarily used for fluid balance monitoring, especially in cases like heart failure or renal conditions. It is not a standard intervention unless specifically indicated for the child’s clinical condition.
Choice B rationale
Routine blood pressure checks every 8 hours are not typically necessary for pediatric patients unless there is a concern for hypertension or critical illness. This intervention is not universally applicable.
Choice C rationale
Seizure precautions are crucial for ensuring patient safety in children with a history or risk of seizures. They include measures such as padded side rails, oxygen availability, and maintaining a safe environment.
Choice D rationale
Sodium-restricted diets are not routinely prescribed for children unless there is an underlying condition like kidney or cardiac disease. This intervention does not apply broadly to pediatric care.
Correct Answer is C
Explanation
Choice A rationale
Bounding peripheral pulses are characteristic of conditions like patent ductus arteriosus or hyperdynamic circulation, not heart failure. Heart failure often causes reduced cardiac output, resulting in weaker pulses. Peripheral vasoconstriction may occur as a compensatory mechanism.
Choice B rationale
Increased blood pressure is not typical in infants with heart failure. Instead, reduced cardiac output usually leads to hypotension or low systolic pressure. Hypertension is more associated with renal disorders or endocrine dysfunctions.
Choice C rationale
Tachycardia is a common manifestation of heart failure as the heart attempts to compensate for diminished cardiac output. Increased heart rate aids in maintaining adequate systemic circulation despite impaired myocardial function.
Choice D rationale
Increased urinary output is inconsistent with heart failure. Reduced cardiac output causes diminished renal perfusion, leading to decreased urine production or potential fluid retention and edema.
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.