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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Elevate the head of the client's bed for 1 hr after the feeding. This is because elevating the head of the client's bed to at least 30 degrees can help prevent aspiration and gastric reflux.
Choice B is incorrect because administering the feeding solution at a cold temperature can cause discomfort and diarrhea.
Choice C is incorrect because rotating the jejunostomy tube once per day can cause irritation and trauma to the stoma site.
Choice D is incorrect because flushing the tube with 90 mL of sterile water before and after the feeding is not necessary as long as the tube is adequately flushed before and after each feeding.
The explanation for why the other choices are not answered: B – Administering the feeding solution at a cold temperature can cause discomfort and diarrhea, so it should not be done. C – Rotating the jejunostomy tube once per day can cause irritation and trauma to the stoma site, so this is not the correct action. D – Flushing the tube with 90 mL of sterile water before and after the feeding is unnecessary to do as long as the tube is adequately flushed before and after each feeding. Thus, this is not the correct answer.
Correct Answer is C
Explanation
The correct answer is choice C. Asthma.
Choice A rationale:
Glaucoma is not a contraindication for propranolol. Beta-blockers like propranolol can actually be used to manage glaucoma by reducing intraocular pressure.
Choice B rationale:
Irritable bowel syndrome (IBS) is not a contraindication for propranolol. There is no direct interaction between propranolol and IBS that would prevent its use.
Choice C rationale:
Asthma is a contraindication for propranolol. Propranolol is a non-selective beta-blocker, which means it can block beta-2 receptors in the lungs, leading to bronchoconstriction and potentially severe asthma exacerbations.
Choice D rationale:
Migraine headaches are not a contraindication for propranolol. In fact, propranolol is often prescribed as a preventive treatment for migraines.
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