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 D

Explanation

A. Replacing the IV site with a smaller gauge does not address the issue of the client picking at the dressing and tape. It is important to address the primary concern, which is the integrity of the abdominal incision dressing.

B. Applying wrist restraints should be avoided unless absolutely necessary due to the risk of physical and psychological harm to the client. It is not the first-line intervention for addressing dressing and tape disruption.

C. Leaving the lights on in the room at night may help reduce confusion in some clients with dementia but does not address the immediate issue of the disrupted abdominal dressing and IV site.

D. Redressing the abdominal incision is the priority intervention to maintain the integrity of the surgical site and prevent infection. It also addresses the issue of the client picking at the dressing and tape, which could lead to further complications.

A. A 16-year-old client diagnosed with major depression who refuses to participate in group. B. A 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby. C. An 18-year-old client with antisocial behavior who is being yelled at by other clients. D. A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack.

Correct Answer is C

Explanation

A. A 16-year-old client diagnosed with major depression who refuses to participate in group:

While refusal to participate may warrant assessment and intervention, it does not indicate immediate danger or escalation.

B. A 17-year-old client diagnosed with bipolar disorder who is pacing around the lobby: Pacing behavior may indicate anxiety or agitation, but it does not necessarily require immediate attention unless there are signs of escalating behavior or safety concerns.

C. An 18-year-old client with antisocial behavior who is being yelled at by other clients: Correct! The client with antisocial behavior being yelled at by other clients indicates a potential conflict or safety issue that requires immediate intervention to prevent escalation or harm to the client or others.

D. A 14-year-old client with anorexia nervosa who is refusing to eat the evening snack: Refusal to eat is concerning in a client with anorexia nervosa, but it does not pose an immediate threat to safety compared to the situation involving potential conflict or aggression.

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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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Correct Answer is D

Explanation

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Correct Answer is C

Explanation

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