The nurse is monitoring a patient recovering from an emergency appendectomy.
Which finding is most concerning?
Absence of bowel sounds
A centimeter spot of bloody drainage on the dressing
Abdomen rigid on palpation
Pain at the operative site .
The Correct Answer is C
Choice A rationale
Absence of bowel sounds can be a normal finding post-operatively and is not necessarily a cause for concern.
Choice B rationale
A small amount of bloody drainage on the dressing is not uncommon after surgery and is not typically a cause for concern.
Choice C rationale
A rigid abdomen on palpation is a concerning finding after an appendectomy. It could indicate peritonitis, a serious infection of the abdominal cavity that can occur if the appendix burst before or during surgery.
Choice D rationale
Pain at the operative site is expected after an appendectomy. However, severe or increasing pain could indicate a complication and should be evaluated by a healthcare provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale
While it’s important to ensure the feeding bag contains enough formula for the feeding period, it’s not recommended to fill the bag with more than 4-6 hours’ worth of formula at a time due to the risk of bacterial growth.
Choice B rationale
This is the correct answer. Flushing the gastrostomy tube with water every 4 hours helps maintain tube patency and hydrates the patient.
Choice C rationale
Changing the feeding bag and tubing every 72 hours is a common practice, but it’s not the most critical intervention in this scenario.
Choice D rationale
Keeping the head of the bed elevated at 30 to 45 degrees during feeding and for 1 to 2 hours afterward is recommended to minimize the risk of aspiration. However, 15 degrees may not be sufficient.
Correct Answer is ["A","C","D"]
Explanation
Choice A rationale
Pain is a subjective experience and can be expressed both verbally and nonverbally. It is important for the nurse to be attentive to both types of expressions to effectively manage the patient’s pain.
Choice B rationale
While it is true that opioids should be used with caution due to the risk of addiction, this statement can be misleading. Opioids are often necessary for managing postoperative pain, and the risk of addiction is low when they are used appropriately and under medical supervision.
Choice C rationale
Considering the patient’s individual expression of pain is crucial in pain management. Pain is a subjective experience and can vary greatly between individuals. Tailoring pain management strategies to the individual patient can improve pain control.
Choice D rationale
Using a pain scale is a common and effective way to monitor the severity of a patient’s pain. It provides a quantifiable measure of pain that can be used to guide treatment decisions.
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