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

Exhibits

Complete the following sentence by using the lists of options.

The child is at risk for developing

as evidenced by their. and.
Answer and Explanation

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

  • Postoperative ileus: Ileus is a common complication after abdominal surgery due to anesthesia, opioid use, and limited mobility. It presents as delayed return of bowel function, marked by absent bowel sounds and abdominal discomfort. In this case, the child has absent bowel sounds and increasing tenderness, supporting this risk.
  • Atelectasis: Atelectasis generally presents with diminished breath sounds and hypoxia, not clear breath sounds. Although the child has shallow respirations and is refusing the incentive spirometer, there are no respiratory findings such as decreased oxygen saturation or adventitious breath sounds that support this condition currently.
  • Peritonitis: Peritonitis would present with systemic symptoms like fever, severe abdominal pain, rebound tenderness, or signs of sepsis. The child has mild abdominal tenderness and stable vital signs, which do not indicate peritoneal inflammation at this time.
  • Urinary retention: This would be characterized by lack of urination, bladder distension, or discomfort—none of which are noted in the scenario. The child’s urinary output and bladder status are not identified as concerns, making this diagnosis unlikely.
  • Absent bowel sounds:  This is a key clinical sign of ileus. After surgery, bowel activity should return gradually. Continued absence of sounds, especially along with abdominal tenderness, strongly indicates impaired gastrointestinal motility.
  • Shallow respirations: While shallow breathing is often a contributing factor to respiratory complications, in the context of abdominal surgery, it also limits diaphragmatic movement, which can further suppress bowel activity and contribute to postoperative ileus.
  • Clear breath sounds:  This is a normal respiratory finding and does not support the presence of atelectasis or other pulmonary complications. It suggests that lung fields are adequately ventilated despite shallow breathing.
  • Intact abdominal dressing: This is an expected postoperative finding and does not support a diagnosis of infection, wound complication, or ileus. It indicates proper surgical wound healing.


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Related Questions

Correct Answer is B

Explanation

A. Allow the second nurse to enter the data while observing them. Even if observed, allowing another person to use a computer while logged in under someone else’s credentials violates HIPAA and security policies.
B. Log off the computer and let the second nurse log on and enter the data. This is the correct and secure action. Each nurse must use their own login to ensure accountability and protect patient confidentiality, as required by HIPAA and institutional policies.
C. Ask the second nurse for the data and enter it for them. This may lead to documentation errors or confusion about who provided care. Each nurse should document their own assessments and interventions.
D. Tell the second nurse to enter the data when they return from their break. While delaying documentation is sometimes necessary, timely documentation is important for safe patient care. The second nurse should have the opportunity to chart promptly, but under their own credentials.

Correct Answer is D

Explanation

A. Place an ice pack over the cast. While this can help reduce swelling and pain, it is a comfort measure, not the priority. Safety assessments must be completed first before implementing non-urgent interventions.
B. Position the casted extremity on a pillow. Elevation is important to reduce swelling, but it follows after ensuring that circulation to the extremity is intact and that there are no signs of vascular compromise.
C. Teach the client to keep the cast clean and dry. Education is essential for long-term cast care, but it is not the first action after cast application. Immediate post-procedural monitoring takes precedence.
D. Palpate the pulse distal to the cast. The nurse should first assess for adequate circulation by checking distal pulses. This helps identify early signs of complications like compartment syndrome or impaired blood flow, making it the highest priority.

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