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
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Related Questions
Correct Answer is D
Explanation
The accessory nerve is tested by evaluating the function of the trapezius and sternocleidomastoid muscles.
The trapezius muscle is tested by asking the patient to shrug their shoulders with and without resistance.
Choice A is wrong because following a light in the six cardinal positions tests the function of cranial nerves III, IV, and VI.
Choice B is wrong because moving their tongue in all directions tests the function of cranial nerve XII.
Choice C is wrong because showing their teeth while smiling tests the function of cranial nerve VII.
Correct Answer is D
Explanation
Cleanse the gums with saline-soaked gauze.
This can help keep the mouth moist and clean, which is important for preventing infection and promoting healing of oral ulcers caused by chemotherapy.
Choice A is wrong because routine oral care should be performed more frequently than every 8 hours.
Choice B is wrong because lemon glycerin swabs can dry out and irritate the mucosa.
Choice C is wrong because oral viscous lidocaine should not be used in children due to the risk of toxicity.
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