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
Lowering room temperature helps reduce fever-related discomfort without overly stressing thermoregulation mechanisms in children. A moderate environmental change can stabilize sweating and vasodilation to maintain core temperature balance, particularly in cases of infection-induced fever like pneumonia.
Choice B rationale
Placing the child in an ice bath may induce cold stress, leading to shivering and paradoxical temperature elevation as the body counteracts drastic environmental cooling. This approach is unsafe and not recommended for managing fever in pediatric care.
Choice C rationale
Administering acetaminophen PO every 2 hours surpasses safe dosing recommendations, risking hepatotoxicity. Acetaminophen acts on the hypothalamus to regulate body temperature, but proper dosing every 4–6 hours is essential for safe fever control.
Choice D rationale
Aspirin is contraindicated in children due to its association with Reye's syndrome, a severe condition causing liver dysfunction and encephalopathy. Pediatric fever should be managed with safer alternatives like acetaminophen or ibuprofen.
Correct Answer is C
Explanation
Choice A rationale
The top of the head near the hairline is associated with the anterior cranial region but does not correspond to the anatomical location of the anterior fontanel. This region contains other bones and is not indicative of the fontanel's position.
Choice B rationale
The middle of the forehead lies superficial to the frontal bone. It is not a marker of the anterior fontanel's position. The fontanel requires palpation of the intersecting cranial bones to locate its true anatomical site.
Choice C rationale
The anterior fontanel is located at the intersection of the frontal and parietal bones, a diamond-shaped membranous area. This area allows for skull flexibility during birth and accommodates brain growth in infants. Palpation of this junction identifies the anterior fontanel accurately.
Choice D rationale
The posterior aspect of the skull features the occipital bone and the posterior fontanel, which is smaller and triangular. This location does not correspond to the anterior fontanel, and palpating this area would not achieve the desired assessment.
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