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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
A. A low phosphorus diet is not typically indicated for liver cirrhosis; instead, a low sodium diet is usually recommended to manage ascites and edema.
B. Noting signs of swelling and edema is important for monitoring fluid retention, a common complication of cirrhosis.
C. Increasing oral fluid intake is not advised without careful assessment due to the risk of fluid overload and worsening of ascites.
D. Monitoring abdominal girth helps in assessing for ascites and its progression, which is crucial in the management of cirrhosis.
E. Reporting serum albumin and globulin levels is important as these can indicate the synthetic function of the liver and help guide treatment.
Correct Answer is C
Explanation
A. When the client has ankle edema Ankle edema may indicate fluid retention, which is common during pregnancy but is not directly related to the assessment of deep tendon reflexes (DTRs).
B. Within the first trimester of pregnancy: Assessing DTRs within the first trimester of pregnancy is not specifically indicated unless there are other signs or symptoms of concern.
C. If the client has an elevated blood pressure: Assessment of DTRs is particularly important if the client has an elevated blood pressure, as it may indicate preeclampsia, a serious pregnancy complication characterized by hypertension and proteinuria.
D. During admission to labor and delivery: While assessment of DTRs may be included in the admission assessment to labor and delivery, it is particularly important to assess DTRs if the client has an elevated blood pressure, as it may indicate preeclampsia.
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
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.