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. Center attention on positive upbeat music . While positive music can be helpful for some individuals in managing anxiety, it may not be effective for everyone, especially those experiencing moderate anxiety.

B. Find outlets for more social interaction: Increasing social interaction may be beneficial for managing anxiety for some individuals, but it may not address the underlying issues contributing to recurrent moderate anxiety.

C. Practice using muscle relaxation techniques: Muscle relaxation techniques, such as progressive muscle relaxation or deep breathing exercises, can help reduce physical tension and promote relaxation, which can be effective in managing anxiety symptoms.

D. Think about reasons the episodes occur: While understanding triggers for anxiety episodes is important, simply thinking about the reasons may not provide immediate relief or effective coping strategies for managing anxiety symptoms.

A. "Which medication works best?" B. "When do you hear voices?" C. "How do you cope with the voices?" D. "What are the voices saying?"

Correct Answer is D

Explanation

A. "Which medication works best?": While medication management is important in treating schizophrenia, asking about medication effectiveness may not provide immediate insight into the nature or content of the hallucinations.

B. "When do you hear voices?": Understanding the timing of hallucinations can provide some context, but it may not directly address the content or impact of the hallucinations on the client's well-being.

C. "How do you cope with the voices?": Understanding coping strategies is valuable, but it may not reveal the specific content of the hallucinations.

D. "What are the voices saying?": This question is crucial because it helps the nurse understand the content and potential themes of the auditory hallucinations, which can inform the treatment plan and interventions for the client's symptoms.

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Body System	Assessment Finding
Cardiovascular	BP 145/89 mmHg Heart Rate 101 bpm Capillary refill 4 seconds
Neurologic	Awake and alert Anxious and Restless
Respiratory	Oxygen saturation 90% Respiratory rate 28bpm Productive cough

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

The nurse is providing education to a client who experiences recurrent levels of moderate anxiety to situations and perceived stress. In addition to information about prescribed medication and administration, which instruction should the nurse include in the teaching?

Correct Answer is C

Explanation

A client with schizophrenia reports auditory hallucinations when admitted to the hospital.What question is most important for the nurse to include in the assessment of this client?

Correct Answer is D

Explanation

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