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","B","D"]
Explanation
Choice A rationale
A nasopharyngeal specimen is crucial for confirming RSV infection. This test detects viral antigens or RNA through assays like immunofluorescence or polymerase chain reaction. Such diagnostic accuracy guides treatment decisions and minimizes misdiagnosis.
Choice B rationale
Sterile suctioning clears nasal secretions, improving airway patency and oxygenation. This intervention is especially necessary before feeding to prevent aspiration, which can exacerbate respiratory distress. Suctioning supports effective feeding by maintaining a clear nasal passage.
Choice C rationale
Nebulized albuterol sulfate is primarily indicated for bronchospasm related to conditions like asthma. While RSV can cause wheezing, bronchodilators are not typically effective for viral-induced airway inflammation and are not a standard treatment for RSV.
Choice D rationale
Administering oxygen to maintain SaO2 above 90% is essential for managing hypoxemia in RSV cases. Oxygen therapy ensures adequate tissue oxygenation, preventing complications like respiratory failure. This is a cornerstone of supportive care for RSV.
Choice E rationale
Chest percussion and drainage are not standard RSV treatments. This intervention targets mucus mobilization in chronic or bacterial respiratory conditions. RSV management focuses on supportive measures like suctioning and hydration rather than percussion.
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.
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