During the first few days after surgery for cleft lip, which intervention should the nurse implement?

Apply Neosporin to avoid Infection.

Apply elbow immobilizers when not being held.

Suction secretions away from the suture line.

Feed Increased amounts of formula to prevent weight loss.

Answer and Explanation

The Correct Answer is C

Suctioning secretions away from the suture line helps maintain the surgical site's cleanliness and promotes healing. It helps prevent accumulation of mucus or oral secretions that can interfere with the healing process and increase the risk of infection. The nurse should use a gentle suctioning technique to avoid disrupting the surgical site.

Applying Neosporin to the surgical site is not typically recommended unless specifically prescribed by the healthcare provider. It is important to follow the provider's instructions regarding wound care.

Applying elbow immobilizers when not being held is not necessary for cleft lip surgery. Elbow immobilizers are usually used in other surgical procedures or for other reasons, such as preventing contractures.

Feeding increased amounts of formula to prevent weight loss is not an appropriate intervention for the first few days after cleft lip surgery. The surgical site may be sensitive, and the child may experience difficulty with feeding initially. The nurse should provide guidance and support for feeding techniques appropriate for the child, which may include using specialized bottles or positioning techniques.

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Correct Answer is ["B","C","D","E"]

Explanation

The initial bundle of care in sepsis includes the following:

Obtain blood cultures: Blood cultures help identify the specific microorganism causing the infection, which is important for guiding appropriate antibiotic therapy.
Administer broad-spectrum antibiotics: Early administration of antibiotics is crucial in sepsis to target the suspected or likely infectious organisms. Broad-spectrum antibiotics cover a wide range of potential pathogens until more specific information from culture results is available.
Obtain lactate levels: Measuring lactate levels helps assess tissue perfusion and can be used as an indicator of the severity of sepsis. Elevated lactate levels are associated with tissue hypoperfusion and increased mortality.
Administer IV fluid bolus: Early aggressive fluid resuscitation is an essential component of sepsis management. Administering intravenous fluids helps restore intravascular volume and improve tissue perfusion.
Administration of vasopressors: Especially in the setting of hypotension and to maintain MAP above 65mmHg.

A. Proteinuria B. Hypocalcemia C. Hypoalbuminemia D. Positive for Ketones

Correct Answer is A

Explanation

The signs or symptoms the nurse would observe in a 4-year-old client experiencing a recurrence of minimal change nephrotic syndrome (MCNS) include:

MCNS is characterized by increased glomerular permeability, leading to the loss of protein, particularly albumin, in the urine. Proteinuria is a hallmark feature of MCNS and is usually detected through urine testing.
Due to the excessive loss of protein in the urine, particularly albumin, the client with MCNS may have low levels of albumin in the blood. Hypoalbuminemia can result in various complications, such as edema formation and impaired immune function. However this is not a sign or symptom.
Edema is a common symptom of MCNS and typically presents as swelling in the face, around the eyes, and in the extremities. This is a result of the fluid shifts and fluid retention caused by the altered glomerular function and hypoalbuminemia.

Hypocalcemia and ketones in the urine are not typically associated with MCNS. Hypocalcemia can occur in some types of kidney disease, but it is not a characteristic feature of MCNS. Ketones in the urine are more commonly associated with conditions like diabetic ketoacidosis or inadequate carbohydrate intake.

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During the first few days after surgery for cleft lip, which intervention should the nurse implement?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The initial bundle of care in sepsis includes which of the following? (Select all that apply.)

Correct Answer is ["B","C","D","E"]

Explanation

The nurse suspects the 4-year-old client is having a recurrence of minimal change nephrotic syndrome (MCNS). Which signs or symptoms would the nurse observe in the client?

Correct Answer is A

Explanation

The nurse is administering nitroprusside by IV infusion for a client in hypertensive emergency. The nurse knows that the primary assessment will be:

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