The nurse is monitoring a patient recovering from an emergency appendectomy.
Which finding is most concerning?

Absence of bowel sounds

A centimeter spot of bloody drainage on the dressing

Abdomen rigid on palpation

Pain at the operative site .

Answer and Explanation

The Correct Answer is C

Choice A rationale
Absence of bowel sounds can be a normal finding post-operatively and is not necessarily a cause for concern.
Choice B rationale
A small amount of bloody drainage on the dressing is not uncommon after surgery and is not typically a cause for concern.
Choice C rationale
A rigid abdomen on palpation is a concerning finding after an appendectomy. It could indicate peritonitis, a serious infection of the abdominal cavity that can occur if the appendix burst before or during surgery.
Choice D rationale
Pain at the operative site is expected after an appendectomy. However, severe or increasing pain could indicate a complication and should be evaluated by a healthcare provider.

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Correct Answer is A

Explanation

Choice A rationale
The most common position for administering an enema is the left lateral position, where the patient lies on their left side with their right leg flexed toward their chest. This position allows for the best flow of the enema solution by gravity along the natural curves of the sigmoid colon and rectum.
Choice B rationale
Position B is not typically recommended for enema administration.
Choice C rationale
Position C is not typically recommended for enema administration.
Choice D rationale
Position D is not typically recommended for enema administration

A. Expect the patient to express his pain both verbally and nonverbally B. Administer opioids with caution because they will eventually lead to addiction C. Consider the patient’s individual expression of pain D. Use a scale from 0 to 10 to monitor the severity of the patient’s pain

Correct Answer is ["A","C","D"]

Explanation

Choice A rationale

Pain is a subjective experience and can be expressed both verbally and nonverbally. It is important for the nurse to be attentive to both types of expressions to effectively manage the patient’s pain.
Choice B rationale
While it is true that opioids should be used with caution due to the risk of addiction, this statement can be misleading. Opioids are often necessary for managing postoperative pain, and the risk of addiction is low when they are used appropriately and under medical supervision.
Choice C rationale
Considering the patient’s individual expression of pain is crucial in pain management. Pain is a subjective experience and can vary greatly between individuals. Tailoring pain management strategies to the individual patient can improve pain control.
Choice D rationale
Using a pain scale is a common and effective way to monitor the severity of a patient’s pain. It provides a quantifiable measure of pain that can be used to guide treatment decisions.

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The nurse is monitoring a patient recovering from an emergency appendectomy. Which finding is most concerning?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is preparing to administer a soapsuds enema to a client. Which position should the client be in to administer the enema?

Correct Answer is A

Explanation

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Correct Answer is ["A","C","D"]

Explanation

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The nurse is monitoring a patient recovering from an emergency appendectomy.
Which finding is most concerning?