A nurse is planning care for a school-age child who is 4 hr postoperative following appendicitis.
Which of the following actions should the nurse include in the plan of care?
Give cromolyn nebulized solution every 6 hr.
Offer small amounts of clear liquids 6 hr following surgery.
Apply a warm compress to the operative site once daily.
Administer analgesics on a scheduled basis for the first 24 hr.
The Correct Answer is D
The correct answer is choice D. Administer analgesics on a scheduled basis for the first 24 hr.
This is because the child is at risk for developing peritonitis, which can cause severe abdominal pain.
Scheduled analgesics can provide better pain relief than PRN analgesics.
Choice A is wrong because the child should not be given anything by mouth until bowel sounds return, which can take up to 24 hr after surgery.
Giving clear liquids too soon can cause nausea, vomiting, and abdominal distension.
Choice B is wrong because cromolyn nebulized solution is used to prevent asthma attacks, not to treat appendicitis.
There is no indication that the child has asthma or needs this medication.
Choice C is wrong because applying a warm compress to the operative site can increase inflammation and infection risk.
A cold compress can be used to reduce swelling and pain, but only if prescribed by the provider.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason
The anterior fontanel is open is the correct answer. An expected finding in an 8-month-old infant is that the anterior fontanel (the soft spot on the top of the baby's head) is open. The fontanelles are spaces between the bones of an infant's skull that allow for the baby's brain to grow and the skull to mould during birth.
The anterior fontanel typically remains open until the baby is around 18 to 24 months old, with the closure process starting sometime after 9 months of age. Therefore, at 8 months of age, it is normal for the anterior fontanel to still be open.
Choice B reason:
Both fontanels are the same size is incorrect. Both fontanels are usually not the same size. The anterior fontanel is larger and diamond-shaped, while the posterior fontanel is smaller and triangular.
Choice C reason:
The posterior fontanel is open is incorrect. The posterior fontanel, located at the back of the baby's head, usually closes earlier than the anterior fontanel. It typically closes within the first few months after birth, so it is not expected to be open at 8 months of age.
Choice D reason
Both fontanels show molding is incorrect. Molding refers to the temporary shaping of the baby's head during birth due to the pressure exerted during the passage through the birth canal. By 8 months of age, the molding typically resolves, and the baby's head should have a more rounded appearance.
Correct Answer is ["A","C"]
Explanation
A: Review the need for the indwelling urinary catheter daily.
This is correct because indwelling catheters should be removed as soon as possible to reduce the risk of urinary tract infection (UTI).
B: Place the drainage bag on the bed when transporting the client.
This is incorrect because the drainage bag should be kept below the level of the bladder and should not touch the floor to prevent the backflow of urine and contamination of the catheter.
C: Use soap and water to provide perineal care.
This is correct because soap and water can help to remove bacteria and debris from the meatus and prevent infection.
D: Encourage the client to drink 3000 mL of fluid daily.
This is incorrect because the client has a fluid restriction of 1000 mL daily due to heart failure. Excessive fluid intake can worsen the client’s condition and increase the workload of the heart.
E: Change the indwelling urinary catheter tubing every 3 days.
This is incorrect because changing the catheter tubing can increase the risk of infection by breaking the closed drainage system. The catheter tubing should only be changed when it is visibly soiled or malfunctioning.
F: Empty the drainage bag when it is half full.
This is incorrect because the drainage bag should be emptied at least every 8 hours or when it is one-third full to prevent back pressure and infection.
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