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 D
Explanation
Choice A reason: Jogging or running are not excellent aerobic exercises for an older adult client with osteoarthritis. These activities can put a lot of stress and impact on the joints, especially the knees, hips, and ankles, which can worsen the pain and inflammation of osteoarthritis. The nurse should advise the client to avoid high-impact exercises that can damage the cartilage and bones.
Choice B reason: Tennis or racquetball are not ideal exercises for an older adult client with osteoarthritis. These activities involve sudden movements, twists, and turns that can strain the joints, especially the elbows, wrists, and shoulders, which can aggravate the symptoms of osteoarthritis. The nurse should advise the client to avoid exercises that can cause joint instability and injury.
Choice C reason: Limiting the exercise to just the daily activities is not a good advice for an older adult client with osteoarthritis. Exercise is important for maintaining joint health, mobility, and function, as well as preventing muscle loss, obesity, and cardiovascular diseases. The nurse should encourage the client to engage in regular moderate exercise that can improve the quality of life and reduce the complications of osteoarthritis.
Choice D reason: Swimming is an excellent exercise for an older adult client with osteoarthritis. Swimming is a low-impact aerobic exercise that can strengthen the muscles, improve the cardiovascular fitness, and enhance the flexibility of the joints without putting too much pressure or stress on them. Swimming can also reduce the pain and stiffness of osteoarthritis by providing a soothing and relaxing effect on the body. The nurse should recommend swimming as a safe and effective exercise for the client.
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