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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Pin site care is essential to prevent infections and other complications associated with external fixation devices. The nurse should instruct the patient to clean the pin insertion sites daily with a sterile saline solution or as per healthcare provider's instructions. The patient should also observe for signs of infection, such as redness, swelling, warmth, and drainage, and report any concerns to the healthcare provider.
Assessing the skin under the foam boot twice daily is not specific to external fixation devices, and it may not be relevant to this patient's care plan. The nurse should focus on teaching the patient about external fixation device care specifically.
Taking prophylactic antibiotics before any dental work for the rest of your life is not relevant to external fixation devices or right lower leg fractures. It is a recommendation for patients with certain heart conditions who may be at risk of developing infective endocarditis during dental procedures.
Removing the external fixator for the shower is not recommended as the device should be kept dry to prevent infections. The nurse should instruct the patient to cover the device with a waterproof dressing or plastic bag during showering to protect it from getting wet.
Correct Answer is ["250"]
Explanation
To calculate the rate at which the nurse should set the IV pump in mL/hr, we need to determine the infusion rate.
The client is receiving 1 gram of antibiotic in 500 ml of fluid over 2 hours. To find the rate in mL/hr, we divide the total volume (500 ml) by the total time (2 hours):
Rate = Volume / Time Rate = 500 ml / 2 hours Rate = 250 ml/hr
Therefore, the nurse should set the IV pump at a rate of 250 mL/hr.
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