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
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
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Avoid bathing this patient until they are stable: Hygiene is essential for preventing infection and promoting comfort. Bathing should not be entirely avoided unless the patient is critically unstable.
B. Only bathe the perineal area: While perineal care is important, other areas also require cleaning, and modifications can be made to prevent excessive exertion.
C. Perform the bath in a semi-Fowler's position: Semi-Fowler's position (30–45°) promotes lung expansion and reduces dyspnea, making it the best position for bathing a patient with breathing difficulty.
D. Delegate the task to the assistive personnel: While an assistive personnel (AP) can assist, the nurse should assess the patient first and be involved in care for clients with respiratory distress.
Correct Answer is D
Explanation
A. "Void every four hours even if you feel like you do not need to urinate." While frequent voiding is beneficial, forcing a rigid schedule is not necessary. The priority is voiding after intercourse and staying hydrated to flush bacteria.
B. "You should perform Kegel exercises several times a day." Kegel exercises strengthen the pelvic floor but do not prevent UTIs.
C. "When possible, you should try to take a tub bath instead of a shower." Soaking in a bath can introduce bacteria into the urethra, increasing UTI risk. Showers are recommended.
D. “It is important to clean front to back during bathing and after using the restroom.” Wiping front to back prevents the spread of bacteria from the perineal area to the urethra, a major cause of UTIs.
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