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 A
A. Teaching the client about ostomy care is important if the Meckel diverticulum was removed and an ostomy was created as part of the surgical procedure.
B. Total parenteral nutrition is not typically indicated following the repair of Meckel diverticulum. Most clients can resume oral intake shortly after surgery.
C. Long-term antibiotic therapy is not typically necessary after the repair of Meckel diverticulum unless there are specific indications for ongoing treatment.
D. Maintaining an NG (nasogastric) tube for decompression is not typically indicated after the repair of Meckel diverticulum. It may be used temporarily if there are concerns about bowel obstruction or ileus, but it is not a long-term intervention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Bilateral cool extremities can indicate decreased peripheral perfusion, which may be a sign of a complication following a cardiac catheterization procedure. This finding should be reported to the provider.
B. A blood pressure of 102/58 mm Hg is within the normal range for a toddler. It does not require immediate reporting to the provider.
C. A serum glucose level of 90 mg/dL is within the normal range for a toddler. It does not require immediate reporting to the provider.
D. A weak pedal pulse distal to the site may be expected after a cardiac catheterization procedure, especially in the immediate postoperative period. However, it should still be monitored and documented, and any significant changes should be reported to the provider.
Correct Answer is D
Explanation
- A: Tighten the screws on the halo device one-quarter turn every 48 hr.
- Rationale: This action is incorrect because the screws on a halo device should not be adjusted by the nurse. The screws are typically set and secured by a healthcare provider, and any adjustments can compromise the integrity of the device and the stability of the cervical spine.
- B: Assess the pin sites for infection once every other day.
- Rationale: While it is important to monitor the pin sites for signs of infection, doing so once every other day may not be sufficient. Pin sites should be assessed at least once per shift to ensure early detection and management of any potential infection.
- C: Encourage flexion and extension of the neck.
- Rationale: This action is contraindicated for a client with a halo vest. The purpose of the halo vest is to immobilize the cervical spine to promote healing. Encouraging neck movement could cause further injury or delay healing.
- D: Reposition the client using a turning sheet.
- Rationale: This is the correct action. Using a turning sheet helps to reposition the client safely and effectively without exerting unnecessary pressure on the cervical spine. It also aids in preventing pressure ulcers and promotes comfort for the client.
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