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

Answer and Explanation

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A. "Tell me about your support system at home." This is an open-ended, therapeutic question that encourages the patient to discuss their support network.

B. "What treatment options has your doctor spoken with you about?" This is an appropriate way to assess the patient's understanding of their diagnosis and plan of care.

C. “I am sure you are scared. Everything will be okay." This statement is nontherapeutic because it offers false reassurance and dismisses the patient’s emotions rather than acknowledging their concerns.

D. "This must be a hard time for you. How are you coping?" This is an empathetic statement that acknowledges the patient's feelings and invites them to express their emotions.

A. Schedule an in person appointment with the provider for the next month. B. Setting up a telehealth visit for the patient. C. Assist the patient in arranging for transportation to and from the appointment D. Ensure that the patient has access to their patient portal

Correct Answer is ["B","D"]

Explanation

A. Schedule an in-person appointment with the provider for the next month: This does not address the challenge of frequent travel or accessibility.

B. Setting up a telehealth visit for the patient: Telehealth reduces travel burdens and allows for frequent monitoring without unnecessary trips.

C. Assist the patient in arranging for transportation to and from the appointment: Assisting the patient in arranging transportation can be beneficial, but telehealth visits offer a more sustainable solution for frequent appointments

D. Ensure that the patient has access to their patient portal: A patient portal allows for easy communication with providers, medication refills, and appointment scheduling.

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Stoma Assessment	Stoma is protruding 2cm, is red and moist. Peristomal area is clean and intact.
Output	Liquid stool that is malodorous. Gas present in the appliance.
General Status	Patient is avoiding looking at the ileostomy during care.
Laboratory Data	Potassium 3.6 mEq/L (normal 3.5 to 5 mEq/L) Sodium 137 mEq/L (normal 135 to 145 mEq/L) Creatinine 0.9 mg/dL (normal 0.6 to 1.2 mg/dL)

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The student nurse is conducting a health history for a patient recently diagnosed with cancer. What statement made by the student would require remediation by the clinical faculty?

Correct Answer is C

Explanation

A patient lives in a rural area and requires frequent appointments related to their health condition. Which of the following interventions should the nurse facilitate?

Correct Answer is ["B","D"]

Explanation

The nurse is providing oral care to a sedated patient. What intervention is most important to implement with this patient?

The nurse is providing indwelling catheter care for a patient who is uncircumcised. What intervention will help prevent a catheter associated urinary tract infection?

Order: Metoprolol Tartrate 25 mg PO each morning Available: Metoprolol Tartrate 50 mg tablets How many tablets will you administer per dose?

A nurse is assessing a client with a stage IV pressure injury. What assessment finding would help them make this determination?

A patient is on isolation for neutropenia. What statement made by the patient requires additional education from the nurse?

The nurse is providing care for patients on the medical-surgical unit. Which of the following situations requires the nurse to implement medical asepsis?