The client is a 7-year-old with spastic cerebral palsy (CP) admitted to pre-op for heel cord lengthening. Child has cognitive and speech delays. Experiences absent seizures numerous times daily according to parent. The nurse is developing the plan of care for the child.
To provide atraumatic care for this child post-operatively, what will be a priority?

Pain assessments

Antibiotics

Occupational therapy

Wound care

Physical therapy

Answer and Explanation

The Correct Answer is A

Assessing and managing pain is a crucial aspect of providing atraumatic care for any post-operative patient, including a child with spastic cerebral palsy. It is important to monitor and assess the child's pain levels regularly to ensure their comfort and

well-being. Pain can be particularly challenging to assess in a child with cognitive and speech delays, so the nurse should use appropriate pain assessment tools and also consider nonverbal cues, changes in behavior, and physiological indicators of pain.

While antibiotics may be prescribed if there is an infection present, it is not mentioned as a priority in this specific scenario. The focus is on providing atraumatic care post-operatively.

Occupational therapy, physical therapy, and wound care are all important components of the child's overall care, but they may not be the immediate priority post-operatively. The child's specific needs and surgical procedure will determine when these interventions are appropriate and can be incorporated into the plan of care as needed. However, addressing pain is of utmost importance in the immediate post-operative period.

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

Explanation

A) Incorrect- Standard precautions are used for all clients to prevent the spread of infections.
However, in the case of MRSA, contact precautions are needed due to the risk of direct transmission through physical contact.
B) Correct- Monitoring the white blood cell count is important to assess for signs of infection, as an elevated count might indicate an ongoing inflammatory response.
C) Correct- Foul-smelling drainage from an incision with suspected MRSA indicates a potential infection. Contact precautions are appropriate for MRSA, which include wearing gloves and gowns when entering the client's room to prevent the spread of the bacteria.
D) Correct- Sending wound drainage for culture and sensitivity helps identify the specific microorganisms causing the infection and guides appropriate antibiotic treatment.
E) Incorrect- A low-bacteria diet is not relevant to the situation. MRSA is caused by a bacterium, not by dietary factors. The focus should be on infection control measures and appropriate medical interventions.

A. Determine when the client last had pain medication. B. Offer to assist the client to the restroom to void. C. Review postoperative instructions with the client. D. Confirm that the client has been NPO since midnight.

Correct Answer is D

Explanation

NPO status is crucial before a surgical procedure, especially when anesthesia will be administered. It helps prevent complications related to aspiration of gastric contents during the procedure. Failure to adhere to the NPO status can lead to serious respiratory problems, such as aspiration pneumonia.

It is important for the nurse to confirm the NPO status with the client to ensure that they have followed the appropriate fasting guidelines. This should be done to ensure the client's safety during the surgery.

While determining when the client last had pain medication, offering assistance to the restroom, and reviewing postoperative instructions are important aspects of preoperative care, confirming NPO status is the most critical nursing action in this particular scenario.

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Naxlex Comprehensive Predictor Exams

A client with foul-smelling drainage from an incision on the upper left arm is admitted with a suspected methicillin-resistant Staphylococcus aureus (MRSA). Which nursing intervention(s) should the nurse include in the plan of care? (Select all that apply.)

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

Explanation

The nurse is assigned to provide care for a client who is scheduled for a laparoscopic cholecystectomy in two hours, at 0900. What nursing action is most important?

Correct Answer is D

Explanation

A client who weighs 110 pounds receives a prescription for dalteparin 150 units/kg subcutaneously daily for 4 months. The medication is available in 7,500 units/0.3 mL prefilled syringe. How many mL should the nurse administer? (Enter numerical value only.)

The nurse is managing the care of a client with Cushing's syndrome. Which intervention(s) should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

A client with a chlamydia infection receives a prescription for a single dose azithromycin 1 gram by mouth. The bottle is labeled "Azithromycin for Oral Suspension, USP 200 mg per 5 mL." How many mL should the nurse administer? (Enter numerical value only.)

Review H and P and nurse's notes. What are the first four actions that the nurse should take?

The nurse is assigned to care for four surgical clients. After receiving report, which client should the nurse see first?

The nurse is evaluating a tertiary prevention program for clients with cardiovascular disease implemented in a rural health clinic. Which outcome indicates the program is effective?