A nurse is assessing a client who is 48 hours postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

Respiratory rate 18/min.

Blood pressure 102/66 mm Hg.

Yellow-green drainage on the surgical incision.

Straw-colored urine from an indwelling urinary catheter.

Answer and Explanation

The Correct Answer is C

Choice A rationale

A respiratory rate of 18/min is within the normal range for adults and does not typically require immediate intervention.

Choice B rationale

A blood pressure of 102/66 mm Hg is within the normal range for adults and does not typically require immediate intervention.

Choice C rationale

Yellow-green drainage from a surgical incision suggests infection and should be reported to the provider immediately for further evaluation and management.

Choice D rationale

Straw-colored urine from an indwelling urinary catheter is a normal finding and indicates adequate hydration and kidney function

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Correct Answer is D

Explanation

Choice A rationale

Removing the vest daily is not recommended as it can disrupt the alignment and stability provided by the halo fixation device.

Choice B rationale

The halo jacket should be snug but not too tight to avoid pressure sores and discomfort.

Choice C rationale

Providing range of motion to the neck is contraindicated as the halo fixation device is meant to immobilize the cervical spine.

Choice D rationale

Monitoring for an elevated temperature is crucial as it can indicate an infection, which is a common complication with halo fixation devices.

A. I have no appetite. B. The pain hurts so much it is making me nauseous. C. When I position myself on my right side, it makes the pain worse. D. The pain seems to be gone now.

Correct Answer is D

Explanation

Choice A rationale

Loss of appetite is a common symptom of appendicitis due to the inflammation and irritation of the gastrointestinal tract. This symptom alone does not indicate an immediate need for intervention.

Choice B rationale

Nausea and vomiting are also common symptoms of appendicitis. The pain and inflammation can stimulate the vomiting center in the brain, leading to nausea. This symptom, while uncomfortable, does not require immediate intervention.

Choice C rationale

Pain that worsens with movement, such as positioning on the right side, is typical of appendicitis. This is due to the irritation of the peritoneum and the inflamed appendix. This symptom is expected and does not require immediate intervention.

Choice D rationale

The sudden disappearance of pain in a patient with appendicitis can indicate a rupture of the appendix. This is a medical emergency as it can lead to peritonitis, a severe and potentially life- threatening infection of the abdominal cavity. Immediate intervention is required to prevent complications.

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A nurse is assessing a client who is 48 hours postoperative following abdominal surgery. Which of the following findings should the nurse report to the provider?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has a halo fixation device. Which of the following actions should the nurse include in the plan of care?

Correct Answer is D

Explanation

A 20-year-old diagnosed with appendicitis is being assessed by the nurse. Which statement by the client will make the nurse intervene immediately?

Correct Answer is D

Explanation

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