A nurse on a pediatric unit is caring for a preschooler who is postoperative following an appendectomy.

Complete the following sentence by using the lists of options.

The child is at risk for developing
_
as evidenced by their
_
.

Answer and Explanation

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

Rationale for correct choices

• Pneumonia: The child has shallow respirations, diminished breath sounds at the bases, and repeated refusal to use the incentive spirometer, all of which decrease lung expansion. Postoperative abdominal pain further limits deep breathing, increasing atelectasis risk that can progress to pneumonia.

• Shallow breathing: Shallow respirations reduce alveolar ventilation and impair airway clearance, predisposing the child to atelectasis and subsequent pneumonia. Pain from the abdominal incision discourages deep breathing, worsening shallow breathing over time. The diminished breath sounds at the lung bases confirm reduced expansion.

Rationale for incorrect choices

• Wound infection: The abdominal dressing remains dry and intact throughout the shift, with no redness, swelling, or drainage. The child’s temperature is only mildly elevated and does not reflect a pattern typical of surgical site infection. Pain is generalized postoperative discomfort rather than localized wound changes. No wound findings suggest progression toward infection.

• Peritonitis: Although abdominal tenderness is present, this is expected after appendectomy and shows no signs of guarding, rigidity, or rebound tenderness. The child remains alert and interactive, which is inconsistent with systemic peritoneal infection. Vital signs remain stable aside from mild tachycardia that can accompany pain. These findings argue against peritonitis.

• Temperature: The temperature remains below the threshold for concern and is only slightly elevated, which is common postoperatively and not specific to pneumonia. Temperature changes alone do not provide clear evidence for the identified risk. More reliable indicators include respiratory patterns and breath sound changes.

• Bowel sounds: Absent bowel sounds are expected for several hours postoperatively and do not relate to respiratory complications such as pneumonia. This finding reflects postoperative ileus rather than pulmonary risk.

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Correct Answer is A

Explanation

A. Delegate scheduled checks to assistive personnel: Regular, scheduled checks help monitor clients with moderate dementia for signs of restlessness, wandering, or unsafe behaviors that could lead to falls. Delegating this task ensures consistent supervision and enhances safety.

B. Ensure all the side rails are up when the client is in bed: Raising all side rails can actually increase the risk of injury, as clients with dementia may attempt to climb over them, leading to falls or entrapment. Side rails should be used judiciously and according to safety guidelines.

C. Collaborate with a provider to request PRN standard prescriptions for sedatives: Routine use of sedatives can increase confusion, dizziness, and fall risk in clients with dementia. Nonpharmacologic fall prevention strategies are preferred whenever possible.

D. Keep televisions on around the unit for distraction: Continuous background noise or television can be overstimulating and may increase agitation in clients with dementia, potentially increasing the risk of falls rather than preventing them.

A. Assault B. Negligence C. False imprisonment D. Battery

Correct Answer is C

Explanation

A. Assault: Assault involves the threat or attempt to cause harm that makes the client fear imminent injury. Hiding the client’s car keys does not involve a threat or intimidation, so it does not meet the criteria for assault.

B. Negligence: Negligence involves failing to provide the standard of care, resulting in harm. While hiding the keys is inappropriate, it is an intentional act rather than a failure to act, so it is not classified as negligence.

C. False imprisonment: False imprisonment occurs when a person is intentionally restrained or confined without legal authority or consent. By hiding the client’s car keys to prevent them from leaving, the AP is restricting the client’s freedom of movement, fulfilling the criteria for false imprisonment.

D. Battery: Battery involves intentional physical contact that is harmful or offensive. Hiding car keys does not involve direct physical contact with the client, so it does not constitute battery.

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A nurse on a pediatric unit is caring for a preschooler who is postoperative following an appendectomy. Complete the following sentence by using the lists of options. The child is at risk for developing _____ as evidenced by their _____ .

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is preparing a staff training on fall prevention for clients who have moderate dementia. Which of the following strategies should the nurse include?

Correct Answer is A

Explanation

A nurse is caring for a client who wants to leave the facility against medical advice. In an attempt to prevent the client from leaving, an assistive personnel (AP) has hidden the client's car keys. Which of the following torts is the AP committing by hiding the client's car keys?

Correct Answer is C

Explanation

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A nurse on a pediatric unit is caring for a preschooler who is postoperative following an appendectomy.

Complete the following sentence by using the lists of options.

The child is at risk for developing
_
as evidenced by their
_
.