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
The correct answer is choice A, participate in reminiscence therapy with the client. This is an effective intervention for individuals with Alzheimer's disease. It involves encouraging the client to discuss past experiences and events. It has been shown to improve mood, decrease agitation, and increase communication skills. The reminiscence therapy should be individualized and tailored to the client's interests and abilities.
- Raising the four side rails on the client's bed is not the correct answer because this could cause harm to the client by restricting their mobility and independence.
- Alternating the client's daily routine is not the correct answer because individuals with Alzheimer's disease benefit from a consistent routine, which helps them to feel more secure and less anxious.
- Keeping the lights dimmed is not the correct answer because it can be disorienting and confusing for clients with Alzheimer's disease, who need adequate lighting to distinguish their surroundings.
Correct Answer is B
Explanation
The correct answer is choice B, which cleans a blood spill with chlorine bleach. This is an appropriate action for infection control because bleach is an effective disinfectant that can kill most pathogens, including bloodborne viruses such as HIV and hepatitis B and C.
A. Rolling soiled linen with the clean side in it before placing it in the laundry bag is not the correct answer because it can spread pathogens and cause cross-contamination.
Performing hand hygiene with hands at elbow level is not the correct answer because it is not the correct technique for hand hygiene, which involves washing hands with soap and water or using an alcohol-based hand sanitizer.
Instructing a female client to wipe the perineal area from back to front is not the correct answer because it can cause contamination of the urethra and increase the risk of urinary tract infections.
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