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 C
Explanation
The correct answer is choice C. Place white tape on the edges of stairs.
Choice A rationale:
While having the furnace inspected is important for safety, it should be done annually, not every two years.Regular inspections help prevent carbon monoxide leaks and ensure the furnace is functioning properly.
Choice B rationale:
Running wires and cords under carpeting is a safety hazard. It can lead to overheating and potentially cause a fire.Additionally, it creates a tripping hazard.
Choice C rationale:
Placing white tape on the edges of stairs is a recommended safety measure.It increases visibility, especially for older adults who may have vision impairments, reducing the risk of falls.
Choice D rationale:
Placing area rugs on wooden floors can be dangerous as they can slip and cause falls.If area rugs are used, they should be secured with non-slip backing or tape.
Correct Answer is B
Explanation
This ABG result indicates that the client has an excess of carbon dioxide (CO2) due to hypoventilation.
A. "Metabolic acidosis" is an incorrect answer because the pH is low and the HCO3 is within normal range.
C. "Respiratory alkalosis" is an incorrect answer because the pH is low and the PaCO2 is elevated.
D. "Metabolic alkalosis" is an incorrect answer because the HCO3 is within normal range, and the pH is low.
Explanation: The ABG result shows a low pH, elevated PaCO2, and normal HCO3, indicating respiratory acidosis. This condition can be caused by conditions that affect breathing, such as pneumonia, asthma, or chronic obstructive pulmonary disease (COPD).
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