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
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","B","C","E"]
Explanation
A. The client takes 2 short naps during the day: The ability to rest indicates decreased hyperactivity and improved regulation of sleep-wake cycles, reflecting early stabilization of manic symptoms.
B. The client engages in quiet activities in their room: Participation in calm, structured activities demonstrates reduced agitation and impulsivity, suggesting improvement in mood stability and ability to focus.
C. The client slept 5 hr the previous night: Improved sleep duration is a positive sign, as insomnia and decreased need for sleep are hallmark symptoms of mania. Achieving rest indicates partial symptom resolution.
D. The client appears to listen to unseen others: Continued auditory hallucinations indicate persistent psychotic features and do not represent improvement. These symptoms require ongoing monitoring and treatment.
E. The client consumes 8 oz of high-calorie fluids each hour: Adequate fluid and calorie intake reflects improved self-care and nutrition, which are often compromised during acute manic episodes. This is a positive indicator of functional recovery.
Correct Answer is A
Explanation
A. Ask the client to rate their pain on a scale of 0 to 10: Pain assessment is the first step in managing pain effectively. Using a standardized pain scale helps determine the severity, effectiveness of the previous dose, and guides subsequent interventions or medication adjustments.
B. Request a prescription for an opioid pain medication for the client: While opioids may be appropriate for breakthrough pain, the nurse must first assess the current pain level and response to prior medication before requesting additional prescriptions. Immediate escalation is premature without assessment.
C. Report this client finding to the provider: Reporting is important if pain persists despite interventions, but initial assessment and documentation of pain severity should precede notifying the provider to provide accurate information.
D. Administer an additional dose of ibuprofen to the client: Administering another dose without verifying timing, maximum daily dosage, or assessing pain response could risk overdose or toxicity. Pain assessment must guide safe medication administration.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.