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 C
Explanation
A. Encourage the client to take sips of diluted fruit juice: Offering small amounts of juice may help introduce oral intake gradually, but it is not the first step. Ensuring the client can safely swallow is essential before providing any oral fluids to prevent aspiration and other complications.
B. Give the client a pureed diet: Transitioning to a pureed diet is part of advancing nutrition after confirming that the client can swallow safely. Starting this too early without assessing swallowing ability can increase the risk of choking or aspiration.
C. Check the client's swallowing reflex: Assessing the swallowing reflex is the priority when tapering a client from TPN. Safe oral intake depends on intact swallowing function, and identifying any deficits early prevents aspiration, aspiration pneumonia, or other serious complications during the transition to oral nutrition.
D. Provide the client with a full liquid diet: A full liquid diet is a step in progressing from TPN to oral intake, but it should only be introduced after confirming the client can swallow safely. Skipping the assessment of the swallowing reflex could place the client at risk for airway compromise.
Correct Answer is A
Explanation
A. "Your device is set to allow you to deliver small doses more frequently.": PCA (patient-controlled analgesia) allows the client to self-administer small, controlled doses of pain medication as needed. This statement accurately explains how the device works and emphasizes client control within safe limits.
B. "Using this device allows you to use less medication than other methods.": While PCA can improve pain management, it does not necessarily reduce the total amount of medication used. The primary benefit is timely pain relief and maintaining therapeutic levels, not automatically using less medication.
C. "Your family member can push the PCA button for you if you're sleeping": Only the client should activate the PCA device to prevent overdose. Allowing others to push the button, a practice called “PCA by proxy,” is unsafe and can lead to serious complications.
D. "You will need to keep track of each dose you administer to avoid taking too much.": The PCA device is programmed with safety limits, including lockout intervals, to prevent overdose. The client does not need to manually track doses, as the device automatically controls and records administration.
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