A 6-week-old infant with poor weight gain is scheduled for a pyloromyotomy. Which pre-operative nursing action has the highest priority?

Mark an outline of the "olive-shaped" mass in the right epigastric area.

Maintain a continuous infusion of IV fluids per prescription.

Monitor amount of intake and infant's response to feedings.

Instruct parents regarding care of the incisional area.

Answer and Explanation

The Correct Answer is B

Choice A reason: Marking an outline of the "olive-shaped" mass in the right epigastric area is not a priority nursing action. The mass is caused by hypertrophy of the pyloric sphincter, which obstructs gastric emptying and causes projectile vomiting. The mass may not be palpable in all cases.

Choice C reason: Monitoring amount of intake and infant's response to feedings is important, but not the highest priority. The infant may have difficulty feeding due to nausea, vomiting, and abdominal pain.

Choice D reason: Instructing parents regarding care of the incisional area is a post-operative nursing action, not a pre-operative one. The parents will need to learn how to keep the incision clean and dry, monitor for signs of infection, and administer pain medication as prescribed.

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Correct Answer is C

Explanation

Choice C is correct because observing the incision site of a client who was discharged home with a suprapubic catheter can help detect signs of infection, bleeding, or healing problems. The nurse should inspect the incision site for redness, swelling, drainage, or odor and report any abnormal findings.

Choice A is incorrect because measuring abdominal girth of a client who was discharged home with a suprapubic catheter is not necessary unless there are signs of urinary retention or obstruction. The nurse should monitor the urine output and color and report any changes.

Choice B is incorrect because assessing perineal area of a client who was discharged home with a suprapubic catheter is not necessary unless there are signs of infection or irritation. The nurse should instruct the client on how to keep the perineal area clean and dry and report any discomfort or discharge.

Choice D is incorrect because palpating flank area of a client who was discharged home with a suprapubic catheter is not necessary unless there are signs of urinary tract infection or kidney involvement. The nurse should ask the client about any pain or tenderness in the flank area and report any positive findings.

A. A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack. B. An 18-year-old client with antisocial behavior who is being yelled at by other clients. C. A 16-year-old client diagnosed with major depression who refuses to participate in group. D. A 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby.

Correct Answer is B

Explanation

Choice A: A 14-year-old client with anorexia nervosa refusing to eat the evening snack is a concern, but it’s not an immediate threat. The nurse can address this issue after dealing with more urgent situations.

Choice B: An 18-year-old client with antisocial behavior being yelled at by other clients requires immediate attention. This situation can escalate quickly and may lead to physical harm or emotional distress for the client.

Choice C: A 16-year-old client diagnosed with major depression refusing to participate in group is a concern, but it’s not an immediate threat. The nurse can address this issue after dealing with more urgent situations.

Choice D: A 17-year-old client diagnosed with bipolar disorder pacing around the lobby might be experiencing agitation or restlessness, but unless they’re showing signs of immediate distress or posing a risk to themselves or others, it’s not the most urgent situation.

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A 6-week-old infant with poor weight gain is scheduled for a pyloromyotomy. Which pre-operative nursing action has the highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

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Correct Answer is B

Explanation

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