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. "Yes! I am sure you are excited to finally eat something. Let's set the head of the bed up." This statement misleads the patient by suggesting they can eat orally, which contradicts the purpose of parenteral nutrition (IV nutrition).
B. "Let me have the provider come explain to you what parenteral nutrition is." While the provider can clarify details, the nurse should explain basic information about parenteral nutrition immediately rather than deferring the question.
C. "Unfortunately, no. We are going to be providing you with nutrition through your vein." This provides a clear, direct, and simple explanation of parenteral nutrition (IV nutrition) while acknowledging the patient's interest in food.
D. "No, we will be putting in a tube that will go from your nose to your stomach to help you eat." This describes enteral nutrition (NG tube feeding), which is different from parenteral nutrition (IV feeding).
Correct Answer is C
Explanation
A. "Everyone knows there are others who can chair this committee better than me." This statement is self-deprecating and does not reflect assertive communication. It shifts responsibility to others instead of setting a clear boundary.
B. "It's just not the right time for me to do this." While this statement declines the opportunity, it leaves room for misinterpretation and follow-up pressure to accept later.
C. "I decline the opportunity at this time." This is a clear, direct, and assertive way to decline without over-explaining or inviting negotiation.
D. "Can you tell me why you chose me?" This response does not decline the role; instead, it invites discussion and may make it harder to say no later.
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