A 7-year-old female child admitted to pre-op for scheduled surgery. Focused assessment completed. Lung sounds are clear to auscultation (CTA), heart sounds clear with normal sinus rhythm, skin clear with no breakdown.
- Abdomen soft with bowel sounds heard in all 4 quadrants.
- A feeding tube is present on the abdomen
- Site is clean and clear.
- Consents for surgery signed by parent at preadmission visit.
- Peripheral IV (PIV) 22 gauge inserted in right forearm with assistance from another nurse.
- Cried throughout procedure.
- Comforted by parent and use of touch music.
- IV fluids at 75 mL/hr started.
Client transported to operating room (OR) and The nurse is developing the plan of care for the child. To provide atraumatic care for this child post-operatively, what will be the priority?
Pain assessments
Antibiotics
Occupational therapy
Wound care
Physical therapy
The Correct Answer is A
Assessing and managing pain is a crucial aspect of providing atraumatic care for any post-operative patient, including a child. The child cried throughout the procedure and will likely experience discomfort and pain after the surgery. It is important to assess the child's pain levels regularly using appropriate pain assessment tools and provide appropriate pain management interventions to ensure their comfort and well-being.
While antibiotics may be prescribed if there is a surgical site infection or specific indications for their use, it is not mentioned as a priority in this scenario. The focus is on providing atraumatic care post-operatively, and pain assessment takes precedence.
Occupational therapy, physical therapy, and wound care are important components of the child's overall care, but they may not be the immediate priority post-operatively.
These interventions can be incorporated into the plan of care as needed, but addressing pain is of utmost importance in the immediate post-operative period.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
These findings suggest potential complications and compromise to the client's circulation and nerve function, which require immediate attention.
Changes in the quality of peripheral pulses indicate alterations in blood flow and may suggest vascular compromise or decreased perfusion to the affected areas. This finding requires immediate intervention to prevent further damage and ensure adequate blood supply to the extremities.
Loss of sensation to the left lower extremity can be indicative of nerve injury or impaired peripheral nerve function. It is important to assess for nerve damage and address it promptly to prevent complications and maximize the client's recovery.
Complaints of increased pain and pressure are concerning because they may indicate the development of compartment syndrome, a serious complication in which pressure within the muscles and tissues builds up to dangerous levels. Prompt intervention is necessary to relieve the pressure and prevent tissue damage.
While sloughing tissue around wound edges and weeping serosanguineous fluid from wounds are important assessment findings in the context of burn care, they do not require immediate intervention compared to the findings mentioned above. These findings should still be addressed and managed appropriately, but they are not considered immediate emergencies.
Correct Answer is ["0.3"]
Explanation
To calculate the mL of dalteparin to administer, we need to determine the total number
of units required for the client and then convert it to the volume based on the concentration provided.
First, we need to calculate the total number of units required: Weight of the client: 110 pounds
Dalteparin dosage: 150 units/kg Duration of treatment: 4 months
To convert the client's weight from pounds to kilograms, we divide it by 2.2: 110 pounds / 2.2 = 50 kilograms
Next, we calculate the total number of units required:
150 units/kg * 50 kilograms = 7,500 units
Now we can calculate the volume to administer:
7,500 units / 7,500 units/0.3 mL = 0.3 mL
Therefore, the nurse should administer 0.3 mL of dalteparin.
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