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 A

Explanation

Epoetin alfa is a medication used to stimulate erythropoiesis, the production of red blood cells. An increase in the client's hemoglobin level indicates that the medication has been effective. The normal range of hemoglobin for adult females is 12-16 g/dL and for adult males is 13.5-17.5 g/dL. A hemoglobin level of 11 g/dL is slightly below the normal range, but it is an improvement from a lower level. Choice B, WBC count 9,000/mm3 is unrelated to the medication and is within the normal range. Choice

C, total calcium 10 mg/dL, and choice D, PT 12 seconds, are also unrelated to the medication and are within the normal range.

Choice B (WBC count 9,000/mm3) is not an answer because it is unrelated to the medication and is within the normal range.

Choice C (total calcium 10 mg/dL) is not an answer because it is unrelated to the medication and is within the normal range.

Choice D (PT 12 seconds) is not an answer because it is unrelated to the medication and is within the normal range.

A. Restrict the diet to clear liquids for 1 to 3 days before the procedure. B. Expect the provider to schedule another procedure to remove any polyps. C. Do not eat or drink anything except water for 12 hours before the procedure. D. Administer enemas 2 days before the procedure.

Correct Answer is C

Explanation

A. This is not necessary for a colonoscopy. A clear liquid diet for a shorter period, usually 12-24 hours, is sufficient.

B: The provider does not schedule another procedure to remove any polyps during the colonoscopy; they may be removed during the procedure or later.

C: This is a standard bowel preparation instruction for colonoscopy to ensure a clear view of the colon during the procedure.

D: While enemas may be part of bowel preparation, they are usually administered closer to the procedure, not 2 days in advance.

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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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