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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

as evidenced by the child's and.
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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Related Questions

Correct Answer is A

Explanation

Rationale:

A. Increased urinary output: Diuresis is expected within the first 12 to 24 hours postpartum as the body eliminates excess fluid retained during pregnancy. Increased urinary output helps reduce blood volume and interstitial fluid accumulated during gestation, making this a normal finding.

B. Temperature 38.2° C (100.0° F): A slight elevation in temperature can occur postpartum due to dehydration or breast engorgement, but 38.2°C is at the upper limit and may suggest infection if persistent. Therefore, it should be monitored rather than considered a typical finding.

C. Presence of lochia serosa: At 12 hours postpartum, lochia rubra, which is bright red and contains blood and tissue debris, is expected. Lochia serosa, which is pink or brown and more serous, typically appears around day 4 postpartum.

D. Deep tendon reflexes 3+: Reflexes of 3+ are slightly brisker than normal and may indicate neurological irritability or preeclampsia if seen with other symptoms. A normal postpartum reflex should be 2+, so this finding requires further evaluation.

Correct Answer is B

Explanation

Rationale:

A. "I will irrigate the colostomy every day.": Colostomy irrigation is used for descending or sigmoid colostomies to regulate bowel movements. It is not recommended for ascending colostomies because the stool is too liquid and unpredictable for effective irrigation.

B. "I will notify my doctor if the stoma starts to look purple.": A healthy stoma should be pink or red and moist. A purple or dusky appearance suggests compromised blood flow or ischemia and should be reported to the provider immediately as it may indicate a serious complication.

C. "I should expect my stool to be formed.": Stool from an ascending colostomy is generally liquid to semi-liquid due to the location in the digestive tract. Formed stool is more typical of descending or sigmoid colostomies, not ascending ones.

D. "I will no longer be able to eat nuts.": While some clients may choose to avoid certain foods based on personal tolerance, there is no absolute dietary restriction against nuts for colostomy clients unless otherwise advised.

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