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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Free Nursing Study Resources

Correct Answer is B

Explanation

"The lesions may reoccur in times of stress." This statement indicates that the client understands that the virus can reactivate and cause new outbreaks during times of stress.

Choice A is not correct because thevirus can spread to other areas through skin-to-skin contact.

Choice C is not correct because the virus can still be contagious even when no lesions are present.

Choice D is not correct because having unprotected sex can still transmit the virus even while taking acyclovir.

A. Temperature change from 36.6° C (97.8° F) to 38.8° C (101.9° F). B. Respiratory rate change from 12/min to 20/min. C. Blood pressure change from 118/78 mm Hg to 86/50 mm Hg. D. Heart rate change from 110/min to 68/min.

Correct Answer is C

Explanation

The correct answer is choice C: Blood pressure change from 118/78 mm Hg to 86/50 mm Hg.

Choice C rationale: A significant drop in blood pressure can indicate various serious conditions, such as shock, hemorrhage, or a severe infection. The nurse should assess the client further and intervene as necessary to prevent complications.

Choice A rationale: The change in temperature may indicate the onset of a fever and requires further assessment, but it is not as immediately concerning as the sudden drop in blood pressure.

Choice B rationale: The change in respiratory rate could be a result of factors like pain, anxiety, or exercise. While it warrants further assessment, it is not as critical as the blood pressure change.

Choice D rationale: The heart rate change may be a response to medications, rest, or other factors. It should be monitored and assessed, but the priority finding is the blood pressure change, which may indicate a more severe underlying issue.

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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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