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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. The weights apply a pulling force continuously: Buck’s traction is a form of skin traction used to immobilize fractures and reduce muscle spasms. The weights must hang freely and provide a constant pulling force to maintain alignment and promote healing.

B. The boot allows active leg movement: In Buck’s traction, the affected leg should be immobilized. Active movement would interfere with the consistent traction force and compromise the effectiveness of the treatment.

C. The footplate rests against the foot of the bed: The client’s foot should not press against the bedframe or footplate, as this can counteract the traction force and cause improper alignment. There should be adequate space for traction to be effective.

D. The weights are just touching the floor: Weights should hang freely and never touch the floor. If they rest on the floor, the traction force is lost, defeating the purpose of the setup and potentially leading to complications.

Correct Answer is B

Explanation

Rationale:

A. Deliver 2 L of oxygen via partial nonrebreather mask: While oxygen can support airway function, it does not address the underlying cause of anaphylaxis. Airway closure due to an allergic reaction requires immediate pharmacologic intervention, not just oxygen delivery.

B. Give epinephrine intramuscularly: Epinephrine is the first-line treatment for anaphylaxis. It counteracts bronchoconstriction, airway edema, and hypotension by stimulating alpha and beta receptors, and should be administered immediately when signs of airway compromise are present.

C. Administer diazepam PO: Diazepam is used for anxiety or seizures, not for acute allergic reactions. It has no effect on reversing airway swelling or bronchospasm and would delay the appropriate emergency treatment needed in this situation.

D. Notify the radiology department: Contacting the radiology department is not relevant or urgent in this scenario. The client is experiencing a life-threatening reaction that requires immediate medical intervention, not communication with non-emergency services.

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