A patient had an appendectomy three days ago and is reporting pain in the lower abdomen of 7/10. After further assessment, the nurse notes the following findings (see table below):
|
Vital Signs |
Blood Pressure: 116/72 Heart Rate: 83 beats per minute Respiratory Rate: 18 breaths per minute Temperature: 98.5F Pulse Oximetry: 99% on room air Pain: 7/10
|
|
Incision Site |
Wound edges are approximated with erythema, warmth and tenderness on palpation. Scant amount of purulent drainage on dressing.
|
Based on these findings, what intervention should the nurse implement?
Administer an antibiotic.
Provide a warm water soak to the area.
Provide education about pain management
Notify the provider about the findings
The Correct Answer is D
A. Administer an antibiotic. While antibiotics may be needed, they must be ordered by the provider. The nurse should notify the provider first to evaluate for infection.
B. Provide a warm water soak to the area. Warm soaks can worsen infection by promoting bacterial growth.
C. Provide education about pain management. While pain management education is important, the wound findings (purulent drainage, warmth, erythema) suggest possible infection, which requires medical intervention first.
D. Notify the provider about the findings. Signs of infection (erythema, warmth, purulent drainage) need to be reported immediately for further evaluation and treatment (e.g., wound culture, antibiotics).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The prescribed dose is 25 mg, and the available tablet strength is 50 mg. To calculate the correct dose:
25 mg ÷ 50 mg= 0.5
Answer: 0.5 tablets
Correct Answer is D
Explanation
A. Administer an antibiotic. While antibiotics may be needed, they must be ordered by the provider. The nurse should notify the provider first to evaluate for infection.
B. Provide a warm water soak to the area. Warm soaks can worsen infection by promoting bacterial growth.
C. Provide education about pain management. While pain management education is important, the wound findings (purulent drainage, warmth, erythema) suggest possible infection, which requires medical intervention first.
D. Notify the provider about the findings. Signs of infection (erythema, warmth, purulent drainage) need to be reported immediately for further evaluation and treatment (e.g., wound culture, antibiotics).
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