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 .
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale
Removing the protective gown before exiting the patient’s room is a standard practice in infection control. However, it is not the most critical action when caring for a client with Clostridioides difficile under contact precautions.
Choice B rationale
Utilizing an electronic thermometer to measure the client’s temperature is a routine part of patient care and is not specific to contact precautions for Clostridioides difficile.
Choice C rationale
Shaking bed linens before placing them in a linen bag can potentially spread Clostridioides difficile spores, increasing the risk of transmission.
Choice D rationale
Taking off the protective gown prior to removing gloves is the correct sequence for doffing personal protective equipment (PPE). This sequence is important to prevent the spread of Clostridioides difficile to the healthcare provider and other patients.
Correct Answer is B
Explanation
Choice A rationale
Pain located in the right lower quadrant is typically associated with conditions such as appendicitis, not diverticulitis.
Choice B rationale
Diverticulitis is often associated with cramping, constant pain in the left lower quadrant. This is because the most common site of diverticula, small bulging pouches that can form in the lining of the digestive system, is in the sigmoid and descending colon, which are located in the left lower quadrant of the abdomen.
Choice C rationale
Sudden onset of pain 2 hours ago is not typically indicative of diverticulitis. While diverticulitis pain can be sudden, it usually worsens over several days.
Choice D rationale
Diarrhea for the past 3 days is not specifically indicative of diverticulitis. While changes in bowel habits can occur with diverticulitis, it is not a defining symptom.
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