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
Choice A Reason:
"Let me know when you want to take the medication.": This statement offers the child autonomy and control over the situation, allowing them to feel empowered to decide when to take the medication.
Choice B Reason:
"The medication isn't bad. It tastes like candy.": This statement might be misleading, as medications often don't taste like candy. It's important to maintain honesty with children about the taste of medication to build trust.
Choice C Reason:
"The medication will treat your hypersensitivity reaction.": While it's important to explain the purpose of the medication, this statement might not resonate well with a preschooler. Using simpler language and a more relatable explanation might be more effective.
Choice D Reason:
"Sometimes, when a child has to take medication, they feel sad.": This statement acknowledges the child's feelings, but it might inadvertently suggest negative emotions associated with taking medication. Instead, it's often better to use positive and reassuring language.
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.
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