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 C
Explanation
Choice AReason:
Exposure to secondhand smoke is incorrect. While exposure to secondhand smoke isn't healthy for anyone, it might not be a primary trigger for seizures in most cases. However, for some individuals, exposure to certain environmental toxins or irritants might exacerbate their condition, though this varies from person to person.
Choice BReason:
Decreased temperature is incorrect. While extreme temperatures (both hot and cold) can potentially trigger seizures in some individuals, decreased temperature alone might not be a common trigger compared to other factors.
Choice C Reason:
Lack of sleep is correct. Sleep deprivation can be a significant trigger for seizures in people with epilepsy or seizure disorders. Maintaining a regular sleep schedule and ensuring adequate sleep is an important aspect of managing seizures in these individuals.
Choice D Reason:
Prolonged headache is incorrect. Headaches can sometimes be a warning sign or an aura before a seizure for some individuals, but having a headache alone might not directly trigger a seizure for most people with a seizure disorder. However, there can be a relationship between headaches and certain types of seizures in specific cases.
Correct Answer is C
Explanation
Correct answer: C
Choice A Reason:
Instructing the child to drink fluids through a straw should be avoided immediately after a tonsillectomy. The sucking motion required when using a straw can potentially disrupt the healing process and dislodge the blood clot at the surgical site, leading to bleeding. Therefore, this action is not recommended.
Choice B Reason:
Avoid milk products such as milk, icecream and pudding initially because they coat the throat, causing the child to cough to clear the throat.
Choice C Reason:
Placing the child in a side-lying position helps maintain an open airway and allows drainage of saliva and potential blood.
Choice D Reason:
Encouraging the child to deep breath and cough is generally a good practice to prevent respiratory complications post-anesthesia. However, immediate post-tonsillectomy, the focus might be more on airway patency and monitoring for signs of bleeding or adverse reactions rather than deep breathing and coughing.
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