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
The correct answer is choice A. Deep tendon reflexes 2+. This indicates that the client is receiving the therapeutic effect of magnesium sulfate, which is to prevent seizures by reducing neuromuscular excitability.
Magnesium sulfate is a mineral that is given intravenously to women with preeclampsia, a condition of high blood pressure and protein in the urine during pregnancy, to reduce the risk of seizures or eclampsia. It can also prolong pregnancy for up to two days, allowing drugs that speed up the baby’s lung development to be administered.
Choice B is wrong because 1+ proteinuria via urine dipstick is not a therapeutic effect of magnesium sulfate, but a sign of preeclampsia.
Proteinuria indicates that the kidneys are not working properly and are leaking protein into the urine. Magnesium sulfate does not improve the outcomes for the baby and can cause side effects such as respiratory depression for the mother.
Choice C is wrong because pulse rate 100/min is not a therapeutic effect of magnesium sulfate, but a possible side effect.
Magnesium sulfate can cause vasodilation, which lowers blood pressure and increases heart rate. A normal pulse rate for an adult is between 60 and 100 beats per minute. A pulse rate higher than 100 beats per minute may indicate tachycardia, which can be caused by various factors such as anxiety, dehydration, fever, infection, or medication.
Choice D is wrong because urine output 20 mL/hr is not a therapeutic effect of magnesium sulfate, but a sign of kidney failure. A normal urine output for an adult is between 800 and 2000 mL per day, or about 30 to 80 mL per hour. A urine output lower than 30 mL per hour may indicate oliguria, which can be caused by various factors such as dehydration, blood loss, shock, or kidney damage. Magnesium sulfate can cause renal toxicity if given in high doses or for prolonged periods.
Correct Answer is B
Explanation
The correct answer is: B
Choice A reason: A social worker may assist clients in many ways, including finding legal representation. However, this statement does not address the client’s concern about the cost of legal representation for advance directives. It’s important to note that while social workers can provide support, they do not eliminate the need for legal representation if the client chooses to seek it.
Choice B reason: This is the correct statement because advance directives do not require legal representation to be valid. They become legally binding when signed in front of the required witnesses. This option directly addresses the client’s concern about affording legal representation by informing them that it is not necessary for the creation of advance directives.
Choice C reason: While medical care can be initiated without advance directives, this statement does not address the client’s concern about the cost of creating advance directives. It also implies that medical care is contingent on the completion of legal documents, which is not accurate.
Choice D reason: Verbal agreements are not as legally binding as written advance directives and could lead to misunderstandings or disputes later on. It is important for the client to have a clear and documented advance directive, which does not necessarily require legal review to be valid.
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