A nurse on a pediatric unit is assisting with the care of a preschooler who is 1 day postoperative following an open appendectomy

Exhibits

Complete the following sentence by using the lists of options.

The preschooler is at greatest risk for developing
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as evidenced by the child's
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and
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.

Answer and Explanation

The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C","dropdown-group-3":"B"}

Rationale:

Pneumonia: The child’s shallow respirations, diminished breath sounds at the bases, and ongoing refusal to use the incentive spirometer suggest decreased lung expansion and poor airway clearance. These are classic risk factors for postoperative pneumonia, especially in pediatric clients who are reluctant to engage in deep breathing exercises.
Peritonitis: Peritonitis would be indicated by signs such as a rigid abdomen, rebound tenderness, or marked fever. The client has mild abdominal tenderness but not the severity or systemic signs expected with peritonitis.
Wound infection: There are no signs of wound infection. The surgical dressing is consistently described as dry and intact with no redness, drainage, or swelling, which are typical indicators of infection.
Temperature: The child's temperature is slightly elevated but remains within the low-grade range and does not independently indicate a serious complication. It’s not the most significant factor in this case.
Bowel sounds: Hypoactive bowel sounds are expected after abdominal surgery and do not directly point to a respiratory complication. They are improving postoperatively and are not a primary concern for pneumonia.
Breathing effort: The child’s consistently shallow respirations and diminished breath sounds show a risk for poor ventilation. These are warning signs for the development of postoperative pneumonia.
Abdominal tenderness: Mild to moderate tenderness is expected 1 day after abdominal surgery and shows improvement over time. It is not strongly suggestive of a new or worsening condition like pneumonia.
Refusal to use incentive spirometer: Using the incentive spirometer encourages deep breathing and lung expansion. Refusing it increases the risk of atelectasis and subsequent pneumonia, especially in pediatric clients with shallow breathing patterns.
Surgical dressing: The dressing is consistently described as dry and intact with no signs of infection or complication. It does not point to any current or developing risk.

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Correct Answer is ["A","B","C","E","G"]

Explanation

Rationale:

Heart rate: A heart rate of 118/min indicates tachycardia, which may be a compensatory response to hypovolemia or blood loss. Combined with low blood pressure and low hemoglobin/hematocrit, it raises concern for active gastrointestinal bleeding and hemodynamic instability.
Stool results: A positive hemoccult test confirms gastrointestinal bleeding, especially when paired with the client’s report of dark, tarry stools (melena). This requires prompt evaluation and may indicate upper GI bleeding, such as from a peptic ulcer.
Current medications: The client is taking high-dose ibuprofen, a nonsteroidal anti-inflammatory drug (NSAID), which can cause or worsen gastric ulcers and bleeding. Continued use should be stopped immediately and replaced with safer alternatives.
WBC count: The WBC count is within the normal range and does not indicate an active infection or inflammatory process at this time. It does not require urgent follow-up compared to other findings.
Hemoglobin and hematocrit: The client’s hemoglobin (9.1 g/dL) and hematocrit (27%) are significantly low, suggesting blood loss likely due to GI bleeding. These values warrant urgent follow-up and possible transfusion depending on symptoms and stability.
Temperature: The client’s temperature of 37.5°C (99.5°F) is slightly elevated but within normal limits and not a priority concern. There are no signs of infection or fever that require immediate follow-up.
Blood pressure: A BP of 90/50 mm Hg indicates hypotension, which is concerning in the context of GI bleeding and low hemoglobin. This may reflect hypovolemia and requires prompt fluid management and monitoring.
Respiratory rate: A respiratory rate of 18/min is within normal limits and does not indicate respiratory distress. It does not require immediate follow-up in this context.

A. "I should do aerobic exercises once per day." B. "I will increase my fluid intake to 1,700 milliliters per day." C. "I should practice pursed-lip breathing exercises." D. "I will consume low-protein, low-calorie foods."

Correct Answer is C

Explanation

Rationale:

A. "I should do aerobic exercises once per day.": While exercise is beneficial for clients with COPD, it should be individualized and not necessarily done daily, especially in the beginning. Overexertion can worsen symptoms, so gradual and well-monitored activity is recommended.

B. "I will increase my fluid intake to 1,700 milliliters per day.": Clients with COPD are typically encouraged to consume 2,000 to 2,500 mL of fluids daily unless contraindicated. Higher fluid intake helps thin secretions, making them easier to expectorate and improving airway clearance.

C. "I should practice pursed-lip breathing exercises.": Pursed-lip breathing improves ventilation by keeping airways open longer during exhalation, reducing air trapping and dyspnea. It is a fundamental breathing technique taught to clients with COPD to improve oxygenation and control shortness of breath.

D. "I will consume low-protein, low-calorie foods.": Clients with COPD often have increased energy demands due to the work of breathing. A high-protein, high-calorie diet is typically recommended to prevent muscle wasting and support respiratory muscle strength.

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Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client who is admitted to the medical-surgical unit Exhibits The nurse is reviewing the client's laboratory findings and vital signs. Select the 5 findings that require immediate follow-up.

Correct Answer is ["A","B","C","E","G"]

Explanation

A nurse is reinforcing teaching with a client who has a new diagnosis of COPD. Which of the following statements by the client indicates an understanding of the teaching?

Correct Answer is C

Explanation

A nurse is contributing to the plan of care for a client who has a chest tube set to continuous suction to relieve a pneumothorax. Which of the following interventions should the nurse include?

The nurse is collecting data on the client on the morning of day 2. Exhibits Which of the following data collection findings indicate an improvement in the client's condition? Select the 4 findings that indicate an improvement.

The nurse is continuing to assist in the care of the client. Exhibits Which of the following actions should the nurse take? Select all that apply.

A nurse is reinforcing teaching about home safety precautions with the parents of a 3-month-old infant. Which of the following instructions should the nurse include in the teaching?

The nurse has reviewed the Vital Signs at 1000. Exhibits Which of the following statements should the nurse include when reinforcing teaching to the client following the procedure? Select all that apply.

A nurse is assisting with the care of a client who has schizophrenia and is actively hallucinating. Which of the following actions should the nurse take?

A nurse is reinforcing teaching with the partner of a client who is receiving hospice care about music therapy for pain management. Which of t following statements by the partner indicates an understanding of the teaching?

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