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

Answer and Explanation

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A) Incorrect - Developing new screening protocols is important, but it doesn't directly indicate that the program has prevented diseases. Screening protocols might catch diseases but don't prevent them.
B) Incorrect - Clients receiving rehabilitation indicates they already had disease complications, which is not a primary prevention outcome.
C) Correct- An improvement in average client scores on risk factor knowledge tests suggests that the primary prevention program has successfully educated clients about behaviors and practices that can help prevent sexually transmitted diseases. This improvement indicates that clients have a better understanding of the risks and protective measures, which is a key indicator of program effectiveness.
D) Incorrect - Diagnosing clients early in their disease process is related to early detection (secondary prevention), not primary prevention.

A. Instruct the mother to change the child's diaper more often. B. Ask the mother to decrease the infant's intake of fruits for 24 hours. C. Encourage the mother to apply lotion with each diaper change. D. Tell the mother to cleanse with soap and water at each diaper change.

Correct Answer is A

Explanation

The excoriated and red skin in the diaper area suggests the presence of diaper dermatitis, which is commonly caused by prolonged exposure to moisture and irritants such as urine and feces. Changing the diaper more frequently helps to minimize the exposure to these irritants and promotes better skin hygiene.

Asking the mother to decrease the infant's intake of fruits for 24 hours is not necessary unless there is evidence of diarrhea or specific dietary concerns. Fruits are generally a healthy part of an infant's diet and do not directly cause diaper dermatitis.

Encouraging the mother to apply lotion with each diaper change may not be recommended in this case, as lotions and creams can further trap moisture and exacerbate the condition. It is best to keep the area clean and dry.

Telling the mother to cleanse with soap and water at each diaper change may be too harsh for the infant's sensitive skin. Plain water or mild, fragrance-free wipes are typically sufficient for cleaning the diaper area. Soap can be drying and irritating to the skin, so it is generally not necessary unless there is a specific indication.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse implements a primary prevention program for sexually transmitted diseases in a nurse-managed health center. Which outcome Indicates that the program was effective?

Correct Answer is C

Explanation

The mother of a 7-month-old brings the infant to the clinic because the skin in the diaper area is excoriated and red, but there are no blisters or bleeding. The mother reports no evidence of watery stools. Which nursing intervention should the nurse implement?

Correct Answer is A

Explanation

Patient Data What other treatments might be helpful for this client? Select all that apply.

The nurse is caring for a client with pulmonary edema who is short of breath and coughing pink tinged sputum. Which position should the nurse place the client to ease respiratory distress?

An older client is taken to the clinic by the spouse, who appears extremely worried. The spouse reports to the nurse that the client started to not make any sense and asked to visit a brother who has been dead for many years. Which action(s) should the nurse take? (Select all that apply.)

Which breakfast selection should the nurse recommend for a 16-year-old with diarrhea?

A client with a history of unstable angina presents to the emergency department with constant chest pressure that is unrelieved with rest. The client appears anxious, pale, and diaphoretic. After obtaining the client's vital signs, which action should the nurse take next?