How it Works
Try Naxlex NCLEX-RN (Free-Trial)

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.


Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Free Nursing Study Resources

Related Questions

Correct Answer is C

Explanation

A. A client who has a forehead wound that is bleeding copiously. Although bleeding may appear dramatic, most scalp wounds bleed heavily and can be controlled with pressure. This is not immediately life-threatening if the client is stable.
B. A client who has a compound fracture of the femur and is crying in pain. This is a serious injury with risk for blood loss and infection, but the client is alert and stable enough to express pain, suggesting less immediate neurologic risk than other clients.
C. A client who was unconscious at the scene and now reports diplopia and nausea. This client likely has a head injury with signs of increased intracranial pressure or concussion (diplopia = double vision, nausea, and prior loss of consciousness). These are neurological red flags and require immediate evaluation to prevent deterioration.
D. A client who has several missing teeth and a swollen, ecchymotic upper lip. While painful and concerning, oral trauma without airway compromise is less urgent than potential brain injury.

Correct Answer is A

Explanation

A. Beneficence. This principle refers to acting in the best interest of the client by promoting their well-being and providing comfort. Sitting with a grieving client to offer emotional support is an act of kindness and compassion, aligning with beneficence.
B. Autonomy. Autonomy involves respecting the client’s right to make decisions about their own care. While important, it is not the primary ethical principle demonstrated in this situation.
C. Fidelity. Fidelity refers to keeping promises and maintaining trust in the nurse-client relationship. While the nurse is being supportive, the act described does not specifically demonstrate the principle of fidelity.
D. Veracity. Veracity involves telling the truth and being honest with clients. It is not the relevant principle in this context, as the focus is on emotional support rather than the communication of factual information.

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

Register