A nurse is planning care for an adolescent following the repair of the Meckel diverticulum. Which of the following actions should the nurse include in the plan of care?
Teach the client about ostomy care.
Administer total parenteral nutrition.
Initiate long-term antibiotic therapy.
Maintain an NG tube for decompression.
The Correct Answer is D
A. Teaching the client about ostomy care is unnecessary because surgical repair of Meckel diverticulum does not typically require an ostomy.
B. Administering total parenteral nutrition (TPN) is not routinely required postoperatively unless there are significant complications affecting digestion.
C. Initiating long-term antibiotic therapy is not standard post-surgical care for Meckel diverticulum repair; antibiotics are usually given short-term to prevent infection.
D. Maintaining an NG tube for decompression is appropriate because postoperative bowel rest is needed to prevent distension and reduce the risk of complications such as ileus.
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Related Questions
Correct Answer is C
Explanation
A. Applying warming blankets is important for maintaining the child's body temperature, but it is not the top priority in this situation.
B. Administering an IV bolus may be necessary, but it is not the priority action. The child's airway and breathing take precedence.
C. This is the correct action. In cases of submersion injury, there is a risk of respiratory distress or failure due to aspiration of water. Assisting with intubation helps ensure a patent airway and adequate oxygenation.
D. Obtaining an arterial blood gas (ABG) sample is an important assessment, but it is not the top priority. Ensuring a patent airway and providing adequate oxygenation come first.
Correct Answer is A
Explanation
A. A respiratory rate of 28 breaths per minute indicates increased respiratory effort, which can be a sign of moderate dehydration. The infant may be trying to compensate for fluid
loss.
B. Capillary refill of 1 second is within the normal range (less than 2 seconds). It is not indicative of moderate dehydration.
C. Weight loss of 7% is a significant amount of weight loss and is indicative of severe dehydration, not moderate dehydration. Moderate dehydration is usually defined as 5- 10% weight loss.
D. Bradycardia (slow heart rate) is not typically associated with dehydration. In fact, tachycardia (fast heart rate) is a more common sign of dehydration.
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