A 2-week-old patient born with a myelomeningocele is to undergo surgical repair of this defect. Which nursing action is of the highest priority in her preoperative care?
Monitoring for apical pulse every hour.
Maintaining the patient in a prone position.
Providing the patient sensory stimulation.
Keeping a strict record of the patient's intake and output.
The Correct Answer is A
Choice A rationale:
Monitoring the apical pulse is of the highest priority for a patient with a myelomeningocele preoperatively. A myelomeningocele is a neural tube defect that can lead to neurologic complications. Monitoring the apical pulse every hour helps detect any signs of cardiac distress or neurological compromise, allowing prompt intervention.
Choice B rationale:
Maintaining the patient in a prone position is not the priority in this situation. While positioning can be important, monitoring vital signs takes precedence over positioning.
Choice C rationale:
Providing sensory stimulation is important for the patient's overall well-being, but it's not the highest priority preoperatively. Monitoring vital signs and assessing for potential complications take precedence.
Choice D rationale:
Keeping a strict record of the patient's intake and output is important for general care, but it's not the highest priority in the immediate preoperative period. Monitoring vital signs and detecting signs of distress come first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale:
Monitoring the stool consistency is a crucial nursing action to assess the effectiveness of pancreatic enzyme replacement therapy. Patients with pancreatic insufficiency, such as those with cystic fibrosis, may have difficulty digesting fats properly. Improved stool consistency, specifically a reduction in greasy and foul-smelling stools, indicates that the pancreatic enzymes are aiding in fat digestion.
Choice B rationale:
Pupillary reflex response assessment is unrelated to pancreatic enzyme replacement therapy. It is more commonly performed to assess neurological status or the effects of medications affecting the autonomic nervous system.
Choice C rationale:
Listening to breath sounds is important for assessing respiratory status, but it does not directly reflect the effectiveness of pancreatic enzyme replacement therapy.
Choice D rationale:
Auscultating the apical pulse rate is a general assessment of cardiovascular function and does not provide information about the effectiveness of pancreatic enzyme replacement therapy.
Correct Answer is B
Explanation
Choice A rationale:
Pedal edema is not indicative of digoxin toxicity. Digoxin toxicity primarily affects the heart's electrical activity and rhythm, not fluid accumulation in the extremities.
Choice B rationale:
Cardiac arrhythmias are a hallmark sign of digoxin toxicity. Digoxin can lead to various types of arrhythmias, such as atrial tachycardia, atrial fibrillation, and ventricular ectopy. This occurs due to the drug's effects on altering the electrical conduction in the heart.
Choice C rationale:
Circumoral cyanosis is not a typical sign of digoxin toxicity. This symptom might be seen in conditions like methemoglobinemia or respiratory distress, but it's not directly related to digoxin toxicity.
Choice D rationale:
Infrequent voiding is not a specific sign of digoxin toxicity. It could be related to various factors, such as fluid intake, renal function, or underlying medical conditions, but it's not a hallmark of digoxin toxicity.
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