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 A

Explanation

A. Assess the patient: The priority action is to assess the patient for injuries before taking any further steps.

B. File a safety event report: This is important but should be done after assessing and ensuring the patient’s safety.

C. Place the patient on fall precautions: While necessary, this is a secondary intervention after assessment and ensuring immediate safety.

D. Get the patient back to bed: Moving the patient before assessing for injuries could worsen potential fractures or other injuries.

A. Chicken noodle soup with Pedialyte and tea B. Chicken broth with Jell-O and coffee. C. Vegetable broth with yogurt and apple juice. D. Tomato soup with a popsicle and water

Correct Answer is B

Explanation

A. Chicken noodle soup with Pedialyte and tea: Chicken noodle soup contains solids (noodles, vegetables, meat), which are not allowed on a clear liquid diet.

B. Chicken broth with Jell-O and coffee: Broth and Jell-O are transparent and fully liquid at room temperature, meeting clear liquid diet guidelines. As long as it is without milk or cream, coffee can be included in the diet.

C. Vegetable broth with yogurt and apple juice: Yogurt is not a clear liquid. Apple juice is okay if filtered, but yogurt makes the meal incorrect.

D. Tomato soup with a popsicle and water: Tomato soup is not clear, as it is opaque and pureed, which disqualifies it from the clear liquid diet.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse enters a patient's room and finds that the patient has fallen on the way to the bathroom. What action should be implemented first?

Correct Answer is A

Explanation

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?

Correct Answer is B

Explanation

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?

A patient has called the nurse to help them ambulate to the bathroom. The nurse assists the patient to a dangling position on the bed and applied the gait belt. Upon standing, the patient reports that they are feeling very dizzy. What is the next best action by the nurse?

A client has developed edema in her lower legs and feet prompting her physician to prescribe furosemide, a diuretic medication. After the client has begun this new medication, what should the nurse anticipate as a normal finding?

A client with a viral upper respiratory infection tells the nurse, "I am so angry because the nurse practitioner would not give me any antibiotics." What would be the most appropriate response by the nurse?

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?

A nurse makes a medication error and fills out an incident report. What will the nurse do with the incident report once it is filled out?

A client with urine retention related to a complete prostatic obstruction requires a urinary catheter to drain the bladder. Which type of catheter is most appropriate for a client that has an obstructed urethra?

You have received a report and are providing skin care for the following patients. Which patient do you want to assess first?