A6-week-old infant with pyloric stenosis is scheduled for a pyloromyotomy, Which pre- operative nursing action has highest priority?

Mark an outline of the "olive-shaped mass in the right epigastric area

Initiate a continuous infusion of IV Fluids per prescription.

Monitor amount of intake and infant's response to feedings.

Instruct parents regarding care of the incisional area.

Answer and Explanation

The Correct Answer is B

A. Marking an outline of the "olive-shaped mass" in the right epigastric area is important for diagnosis, but not a priority pre-operatively.
B. Initiating a continuous infusion of IV fluids is crucial to ensure the infant is properly hydrated before the procedure, as pyloric stenosis can cause severe dehydration.
C. Monitoring the amount of intake and the infant's response to feedings is part of ongoing care, but immediate pre-operative hydration takes precedence.
D. Instructing parents regarding care of the incisional area is necessary post-operatively, not before the surgery.

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Correct Answer is C

Explanation

A. Yellow-tinged sputum is not uncommon in patients with pneumonia and while it should be monitored, it is not typically a sign of an adverse reaction to linezolid.

B. Nausea and headache may occur with many medications and are not specific to linezolid; these symptoms should be reported, but they are not the most critical.

C. Watery diarrhea could indicate a potentially serious condition known as Clostridium difficile- associated diarrhea, which is an important complication to report when a patient is on antibiotics like linezolid.

D. Increased fatigue can be associated with the client's underlying condition of pneumonia and while it should be assessed, it is not the most critical finding to report in relation to linezolid therapy.

A. Notify the emergency response team of the client's seizure. B. Keep orienting the client to time and space until he is less confused. C. Explain the postictal state that usually follows seizures. D. Ask the wife to wait outside the room until the nurse can talk with her. E. None F. None

Correct Answer is C

Explanation

A. Notify the emergency response team of the client's seizure: While the seizure is significant, it lasted less than 1 minute and resolved spontaneously. There is no need to call an emergency response team unless complications arise or the seizure becomes prolonged.
B. Keep orienting the client to time and space until he is less confused: While supportive, this is not the priority. Postictal confusion is expected and does not usually require active reorientation until the client regains baseline status.
C. Explain the postictal state that usually follows seizures: Providing reassurance and education to the spouse about postictal symptoms (such as confusion, lethargy, and altered responsiveness) is appropriate and therapeutic. It addresses her concern while monitoring the client for further changes.
D. Ask the wife to wait outside the room until the nurse can talk with her: This action excludes the spouse unnecessarily and delays communication. Involving the family promotes trust and understanding.

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A6-week-old infant with pyloric stenosis is scheduled for a pyloromyotomy, Which pre- operative nursing action has highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

In caring for a client who is receiving linezolid IV for nosocomial pneumonia, which assessment finding is most important for the nurse to report to the healthcare provider?

Correct Answer is C

Explanation

Correct Answer is C

Explanation

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