A nurse is caring for an adolescent who is 1 hr postoperative following an appendectomy.
Which of the following findings should the nurse report to the provider?
Muscle rigidity.
Abdominal pain.
Temperature 36.4° C (97.5° F).
Heart rate 63/min.
The Correct Answer is A
Muscle rigidity following an appendectomy could be a sign of a serious complication such as peritonitis and should be reported to the provider immediately.
Choice B is wrong because abdominal pain is a common occurrence following an appendectomy and may not necessarily require immediate attention from the provider.
Choice C is wrong because a temperature of 36.4° C (97.5° F) is within the normal range.
Choice D is wrong because a heart rate of 63/min is within the normal range for an adolescent.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The nurse should first check the pH of the gastric secretions to confirm the placement of the NG tube before administering the enteral feeding.
Choice A is wrong because flushing the tube with water should be done after confirming the placement of the NG tube.
Choice B is wrong because attaching the feeding bag tubing to the end of the NG tube should be done after confirming the placement of the NG tube.
Choice D is wrong because setting the administration rate on the feeding pump should be done after confirming the placement of the NG tube.
Correct Answer is D
Explanation
The nurse should prepare the toddler for nasotracheal intubation first because the toddler is experiencing severe dyspnea and drooling, which are signs of airway obstruction.
Nasotracheal intubation will help to secure the toddler’s airway and improve their breathing.
Choice A is wrong because administering an antibiotic is not the priority intervention for a toddler with airway obstruction.
Choice B is wrong because obtaining a blood culture is not the priority intervention for a toddler with airway obstruction.
Choice C is wrong because inserting an IV catheter is not the priority intervention for a toddler with airway obstruction.
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