The nurse is caring for a client who had an appendectomy 4 hours ago. Which finding requires immediate action by the nurse?
Redness and edema noted at the incision site.
Apical heart rate of 100 to 110 beats/minute.
High-pitched sound heard upon inspiration.
Pain rating of 8 on a scale of 0 to 10.
The Correct Answer is C
Choice A reason: Redness and edema noted at the incision site are signs of inflammation, which are normal in the early stages of wound healing. The nurse should monitor the site for signs of infection, such as purulent drainage, increased pain, or fever.
Choice B reason: Apical heart rate of 100 to 110 beats/minute is a sign of tachycardia, which may be caused by pain, anxiety, dehydration, or blood loss. The nurse should assess the client's vital signs, fluid status, and hemoglobin level, and administer pain medication as prescribed.
Choice C reason: High-pitched sound heard upon inspiration is a sign of stridor, which is a life-threatening emergency that indicates airway obstruction. The nurse should call for help, administer oxygen, and prepare for intubation or tracheostomy.
Choice D reason: Pain rating of 8 on a scale of 0 to 10 is a sign of severe pain, which may impair the client's recovery and increase the risk of complications. The nurse should administer pain medication as prescribed and use non-pharmacological methods to relieve pain, such as positioning, distraction, or relaxation techniques.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: This is incorrect because sleeping with the head ofthe bed flat can worsen OSA by allowing gravity to pull down on the soft tissues ofthe throat and obstructing airflow.
Choice B reason: This is incorrect because taking sedatives prior to sleep can also worsen OSA by relaxing the muscles ofthe upper airway and increasing airway collapse.
Choice C reason: This is correct because beginning a weight loss program can help reduce OSA by decreasing fat deposits around the neck and chest that can compress and narrow the airway.
Choice D reason: This is incorrect because drinking 1to 2 glasses of wine at bedtime can have similar effects as sedatives, such as relaxing the muscles ofthe upper airway and impairing the respiratory drive.
Correct Answer is C
Explanation
Choice A reason: Lifting and clearing drainage from the chest tube is not necessary, as the water level fluctuations indicate that the chest tube is functioning properly and allowing air and fluid to escape from the pleural space.
Choice B reason: Inspecting the tube insertion site for leaking is not indicated, as there is no evidence of air leak in the water-seal chamber. An air leak would cause continuous or intermittent bubbling in the water-seal chamber.
Choice C reason: Continuing to monitor the drainage system is the best action for the nurse to implement, as the water level fluctuations are normal and expected in a water-seal drainage system. The water level should rise during inspiration and fall during expiration, reflecting the changes in intrathoracic pressure.
Choice D reason: Auscultating lungs for unequal breath sounds is not relevant, as it does not address the question of what to do with the water level fluctuations. Unequal breath sounds may indicate a pneumothorax or atelectasis, which are complications of chest trauma or chest tube insertion.
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