A patient had an appendectomy three days ago and is reporting pain in the lower abdomen of 7/10. After further assessment, the nurse notes the following findings (see table below):

Vital Signs

Blood Pressure: 116/72

Heart Rate: 83 beats per minute

Respiratory Rate: 18 breaths per minute

Temperature: 98.5F

Pulse Oximetry: 99% on room air

Pain: 7/10

Incision Site

Wound edges are approximated with erythema, warmth and tenderness on palpation. Scant amount of purulent drainage on dressing.

Based on these findings, what intervention should the nurse implement?

Administer an antibiotic.

Provide a warm water soak to the area.

Provide education about pain management

Notify the provider about the findings

Answer and Explanation

The Correct Answer is D

A. Administer an antibiotic. While antibiotics may be needed, they must be ordered by the provider. The nurse should notify the provider first to evaluate for infection.

B. Provide a warm water soak to the area. Warm soaks can worsen infection by promoting bacterial growth.

C. Provide education about pain management. While pain management education is important, the wound findings (purulent drainage, warmth, erythema) suggest possible infection, which requires medical intervention first.

D. Notify the provider about the findings. Signs of infection (erythema, warmth, purulent drainage) need to be reported immediately for further evaluation and treatment (e.g., wound culture, antibiotics).

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. A 32-year-old with menstrual cramps. Cold therapy can help relieve pain and reduce pelvic inflammation.

B. A 78-year-old with peripheral arterial disease. Cold therapy causes vasoconstriction, which can further reduce circulation in clients with PAD, increasing the risk of tissue damage.

C. A 44-year-old with a hematoma to the leg: Cold therapy is recommended for hematomas as it reduces swelling and bleeding.

D. A 69-year-old with a pulled muscle: Cold therapy reduces inflammation and numbs pain, making it beneficial for muscle injuries.

A. Powered stand assist B. Cane C. Gait belt D. Four wheel walker

Correct Answer is C

Explanation

A. Powered stand assist: Powered stand assist devices are used for clients who cannot bear weight independently, not for balance issues during ambulation.

B. Cane: A cane provides minimal support and is best for clients with mild weakness, not for those with frequent balance loss.

C. Gait belt: A gait belt provides stability and support while allowing the nurse to assist the client safely if they begin to lose balance.

D. Four-wheel walker: A four-wheel walker rolls easily, which may increase fall risk in a client with balance issues. A standard walker (without wheels) would be safer in some cases.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Which of the following clients should avoid the use of cold therapy?

Correct Answer is B

Explanation

A nurse is assisting an older adult client who sometimes loses their balance while walking. Which of the following devices is most important for the nurse to use when helping the client ambulate?

Correct Answer is C

Explanation

A patient is on isolation for neutropenia. What statement made by the patient requires additional education from the nurse?

The nurse is providing care for patients on the medical-surgical unit. Which of the following situations requires the nurse to implement medical asepsis?

The nurse is caring for a patient admitted with weakness and has a history of osteoporosis and obesity. What nursing intervention should the nurse implement while providing hygiene care?

While bathing a patient who is on bedrest, the nurse notes an area of blistering and hypopigmentation on the patient's right heel. Upon further assessment, the area is also tender and cooler than the surrounding area. What is the next best action by the nurse?

The nurse is assessing the patient's output for the shift. What finding is most concerning?

A patient lives in a rural area and requires frequent appointments related to their health condition. Which of the following interventions should the nurse facilitate?

You are providing care for a patient on a clear liquid diet. You know your teaching about the clear liquid diet has been effective when the patient chooses which of the following meals?

The nurse is attempting to develop a therapeutic nurse-client relationship with a newly admitted client. What expectations does the nurse have when developing the relationship?