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
Heart rate 63/min
Temperature 36.4° C (97.5" F)
The Correct Answer is A
Choice A Reason:
Muscle rigidity is correct. Muscle rigidity can indicate several concerning issues postoperatively, such as complications from anesthesia, infection, or other underlying problems. It's crucial to report this finding promptly to the provider for further evaluation and appropriate management.
Choice B Reason:
Some degree of abdominal pain is expected post-appendectomy, but the severity and persistence of the pain should be assessed further.
Choice C Reason:
Heart rate of 63/min is within the normal range for some adolescents and might not be an immediate concern unless there are other accompanying symptoms.
Choice D Reason:
A temperature of 36.4°C (97.5°F) falls within the normal range for body temperature and might not be a cause for immediate concern unless it's accompanied by other symptoms or if there are signs of temperature changes (like fever) over time.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Check the pH of the gastric secretions."Checking the pH of the gastric secretions is crucial to confirm that the NG tube is correctly positioned in the stomach. This helps ensure that the tube is in the right place before administering the feeding, thereby reducing the risk of complications such as aspiration.
B. "Attach the feeding bag tubing to the end of the NG tube."Attaching the feeding bag tubing should be done after verifying the tube's placement and ensuring it is in the stomach. This step is important, but it follows confirmation of correct tube placement.
C. "Flush the tube with water."Flushing the tube with water is important to ensure patency and prepare the tube for feeding. However, this should only be done after confirming the tube's placement.
D. "Set the administration rate on the feeding pump."Setting the administration rate is necessary for administering the feeding but should be done after confirming tube placement and preparing the tube.
Correct Answer is C
Explanation
Choice A Reason:
A school-age child who has diabetes mellitus and a blood glucose of 200 mg/dL. A blood glucose level of 200 mg/dL in a child with diabetes may require management but is not an immediate life-threatening situation.
Choice B Reason:
A toddler who has nephrotic syndrome and facial edema. Facial edema in a child with nephrotic syndrome requires assessment and potential intervention but might not present an immediate threat to life compared to an airway obstruction.
Choice C Reason:
A preschool-age child who has a muffled voice and no spontaneous cough. The combination of muffled voice and the absence of spontaneous cough can be indicative of an upper airway obstruction, which can be life-threatening. This requires immediate assessment and intervention to ensure the child's airway is clear and that breathing is not compromised.
Choice D Reason:
An adolescent who has Crohn's disease and a recent weight loss of 5 kg (11 lb). Weight loss in an adolescent with Crohn's disease is concerning but might not represent an immediate life-threatening situation compared to a potential airway obstruction.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.