A nurse is caring for a patient who is one day postoperative following an appendectomy. What findings should the nurse report?
Hypoactive bowel sounds in all four quadrants.
Red streaks along the incision.
Serosanguineous drainage at the incision site.
Temperature 37.2 C (99 F).
The Correct Answer is B
Choice A rationale
Hypoactive bowel sounds in all four quadrants are not unusual in a patient one day postoperative following an appendectomy. This is because anesthesia and surgery can slow down the bowel movements temporarily.
Choice B rationale
Red streaks along the incision are a sign of infection. This could indicate cellulitis, a common skin infection that can be serious if left untreated. The red streaks are often warm to the touch and may be accompanied by other signs of infection such as fever, pain, and swelling.
Therefore, the nurse should report this finding.
Choice C rationale
Serosanguineous drainage at the incision site is not uncommon in the first few days after surgery. It is a mixture of blood and serum and is usually light pink to blood-tinged in color. However, if the drainage is heavy, or if it continues for more than a few days, it could be a sign of a problem such as infection or poor wound healing.
Choice D rationale
A temperature of 37.2 C (99 F) is within the normal range for body temperature. A slight elevation in temperature can be expected after surgery due to the body’s inflammatory response to the surgical trauma.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Avoiding administration of the influenza vaccine is not a recommended intervention for a patient experiencing sickle cell crises. Vaccinations are important for patients with sickle cell disease to prevent infections that can trigger crises.
Choice B rationale
Providing a diet that is low in protein is not a recommended intervention for a patient experiencing sickle cell crises. Patients with sickle cell disease need a balanced diet that includes adequate protein to support tissue repair and growth.
Choice C rationale
Decreasing fluid intake to 1,500 mL daily is not a recommended intervention for a patient experiencing sickle cell crises. Adequate hydration is important to prevent sickling of cells and to maintain blood volume.
Choice D rationale
Maintaining the patient on bed rest is the correct intervention. Rest can help to decrease the body’s demand for oxygen, reduce stress on the body, and prevent complications such as acute chest syndrome.
Correct Answer is A
Explanation
Choice A.
Choice A rationale
A platelet count of 60,000/mm is significantly lower than the normal range of 150,000 to 400,000/mm. Platelets are crucial for blood clotting, and a low count can increase the risk of bleeding, which is a serious concern for a patient scheduled for a liver biopsy. Therefore, the nurse should report this value to the provider.
Choice B rationale
An ammonia level of 55 mcg/dL falls within the normal range of 10 to 80 mcg/dL1. Ammonia is a byproduct of protein metabolism and is converted to urea in the liver for excretion. Normal levels do not typically pose a concern for liver biopsy.
Choice C rationale
Aspartate aminotransferase (AST) is an enzyme found in various tissues, including the liver. An AST level of 34 units/L is at the upper limit of the normal range (0 to 34 units/L)1. While it’s
important to monitor, it does not necessarily need to be reported to the provider before a liver biopsy if there are no other signs of liver disease.
Choice D rationale
A bilirubin level of 1.0 mg/dL is within the normal range (0.3 to 1.0 mg/dL)1. Bilirubin is a waste product from the breakdown of red blood cells and is processed by the liver. Normal levels indicate that the liver is functioning properly in this regard.
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