A nurse is assisting with the plan of care for a child who is 12 hr postoperative following a ruptured appendix with peritonitis. Which of the following actions should the nurse include in the plan of care?
Give pain medications on a schedule.
Initiate contact isolation.
Offer clear liquids.
Maintain strict bed rest.
The Correct Answer is A
Choice A reason:
Providing pain medication on a schedule is important for managing pain and ensuring the child's comfort, especially after a surgery involving peritonitis.
Choice B reason:
Contact isolation is not typically indicated for a child postoperative for appendicitis unless there is a specific infectious concern. It is not a routine intervention.
Choice C reason:
Offering clear liquids may be appropriate depending on the child's individual recovery and surgeon's orders. However, this should be determined on an individual basis and is not a standard postoperative intervention.
Choice D reason:
Maintaining strict bed rest may not be necessary for all children postoperative for appendicitis. Early mobilization and ambulation are often encouraged to promote recovery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A reason:
Taping the wire to the palm of the hand can be uncomfortable for the child and may interfere with blood flow.
Choice B reason:
Warming the skin prior to probe placement is not a standard practice for pulse oximetry monitoring.
Choice C reason:
Applying the sensor to the index fingernail is not a recommended site for pulse oximetry monitoring in children.
Choice D reason:
Repositioning the probe every 2 hours helps to prevent skin breakdown and ensures accurate readings over time. This is a standard practice in pulse oximetry monitoring.
Correct Answer is C
Explanation
Choice A reason:
A subdural hematoma may not directly affect the fontanels. Depressed fontanels can be a sign of dehydration or other underlying conditions, but they are not specifically associated with a subdural hematoma.
Choice B reason:
A subdural hematoma would not typically cause a decrease in body temperature. This finding may be related to other factors, but it is not a characteristic sign of a subdural hematoma.
Choice C reason:
Correct. A subdural hematoma is a collection of blood between the dura mater and the brain. This can lead to increased intracranial pressure and result in the infant being difficult to arouse.
Choice D reason:
While a weak cry can be an indication of distress or illness in an infant, it is not a specific sign of a subdural hematoma. Other assessments, including neurological signs, are crucial in evaluating the infant's condition.
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