A nurse is caring for a client who is 1 day postoperative following an appendectomy. Which of the following findings should the nurse report?

Temperature 37.2° C (99° F)

Serosanguineous drainage at the incision site

Red streaks along the incision

Hypoactive bowel sounds in all four quadrants

Answer and Explanation

The Correct Answer is C

Red streaks along the incision. This is a possible sign of infection and should be reported to the healthcare provider. A temperature of 37.2°C (99°F) is within the normal range and does not require reporting. Serosanguineous drainage at the incision site is normal within the first few days postoperatively. Hypoactive bowel sounds in all four quadrants can indicate ileus, which is a possible complication following abdominal surgery, but it is not an immediate concern and can be monitored unless other symptoms arise.

Choice A: A temperature of 37.2°C (99°F) is within the normal range and does not require reporting.

Choice B: Serosanguineous drainage at the incision site is normal within the first few days postoperatively.

Choice D: Hypoactive bowel sounds in all four quadrants can indicate ileus, which is a possible complication following abdominal surgery, but it is not an immediate concern and can be monitored unless other symptoms arise.

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Correct Answer is B

Explanation

A platelet count of 60,000/mm² is below the expected reference range, and the nurse should report this value to the provider. Ammonia, aspartate aminotransferase, and bilirubin values are within expected reference ranges and do not require further reporting.

Other choices are not correct because:

A. Ammonia 55 mcg/dL: Is within the expected reference range and does not require further reporting.

C. Aspartate aminotransferase 34 units/L: Is within the expected reference range and does not require further reporting.

D. Bilirubin 1.0 mg/dL: Is within the expected reference range and does not require further reporting.

A. Apply a motion sensor mat to the client's bed. B. Move the overbed table away from the bed. C. Raise all four side rails while the client is in bed. D. Leave the television on in the client's room.

Correct Answer is A

Explanation

The correct answer is choice A, apply a motion sensor mat to the client's bed. This is an effective intervention to monitor the client's movements and prevent falls. The mat is placed under the bed sheet and will sound an alarm if the client tries to get out of bed.

Moving the overbed table away from the bed is not the correct answer because it does not prevent falls.
Raising all four side rails while the client is in bed is not the correct answer because it can cause the client to feel trapped and can lead to injuries if they try to climb over the rails.
Leaving the television on in the client's room is not the correct answer because it can be distracting and interfere with the client's sleep.

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A nurse is caring for a client who is 1 day postoperative following an appendectomy. Which of the following findings should the nurse report?

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