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 A

Explanation

A. The client's desire to go home so soon after a significant medical event like an MI suggests a possible denial of the severity of his condition and an unwillingness to acknowledge the
need for further medical care and recovery time.

B. While decisional conflict due to stress could be a concern, the client's behavior does not directly indicate stress about making decisions, but rather a disregard for the gravity of his recent health event.
C. Deficient knowledge of lifestyle changes is likely an issue for someone who has just experienced an MI, but the immediate behavior of wanting to leave the hospital does not directly relate to a lack of knowledge about necessary lifestyle changes.
D. Anxiety related to the treatment plan could be present, but the client's behavior of wanting to leave the hospital suggests a coping mechanism of denial rather than anxiety about the treatment itself.

A. An abdominal binder can be worn daily to reduce the protrusion. B. This hernia is a normal variation that resolves without treatment. C. The quarter should be secured with an elastic bandage wrap. D. Restrictive clothing will be adequate to help the hernia go away.

Correct Answer is B

Explanation

A. An abdominal binder can be worn daily to reduce the protrusion: This is not an appropriate intervention for an umbilical hernia in an infant. Abdominal binders are typically used for support after abdominal surgeries or to manage hernias in adults.

B. This hernia is a normal variation that resolves without treatment: Umbilical hernias are common in infants and typically resolve on their own without intervention by around 1 to 2 years of age. Reassuring the mother about the benign nature of the hernia is appropriate.

C. The quarter should be secured with an elastic bandage wrap: Taping a quarter over the umbilicus is not a recommended treatment for an umbilical hernia and could pose a choking hazard to the infant.

D. Restrictive clothing will be adequate to help the hernia go away: Restrictive clothing is not an effective treatment for umbilical hernias in infants and could potentially cause discomfort or complications.

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

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Naxlex Comprehensive Predictor Exams

A 46-year-old male client who had a myocardial infarction (MI) 24-hours ago comes to the nurse's station fully dressed and wanting to go home. He tells the nurse that he is feeling much better at this time. Based on this behavior, which client problem should the nurse include in the plan of care?

Correct Answer is A

Explanation

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Correct Answer is B

Explanation

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