The nurse is caring for a 13-year-old who is 2 days post-operative from a laparoscopic appendectomy. Upon assessment, the nurse notes the following vital signs: 37,1°C (98.8°F), a pain rating of 3 out of 10, and breath sounds are diminished in the lower lobes. What action should the nurse take first?

Maintain prone positioning.

Request a laboratory prescription for a white blood cell count.

Administer prescribed acetaminophen.

Encourage the use of an incentive spirometer.

Answer and Explanation

The Correct Answer is D

A. Prone positioning is not recommended post-operatively for abdominal surgery and could exacerbate respiratory issues.

B. While monitoring white blood cell count is important, encouraging lung expansion and preventing complications such as atelectasis is a more immediate priority.

C. The client's pain rating is low and does not necessitate immediate administration of acetaminophen.

D. Encouraging the use of an incentive spirometer helps improve lung expansion, which is crucial to prevent atelectasis and promote proper oxygenation, particularly when breath sounds are diminished.

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Correct Answer is C

Explanation

A. A complete blood count is not specifically required before administering the rubella vaccine.

B. Lead screening is not related to rubella vaccination and is not required for this purpose.

C. The rubella vaccine is a live attenuated vaccine, and it is important to ensure that the patient is not pregnant because the vaccine could potentially harm the fetus. Therefore, a pregnancy test is a necessary precaution.

D. Tuberculosis screening is not related to the rubella vaccination and is not required for this purpose.

A. Apply topical diphenhydramine to affected site. B. Apply a cool pack to reduce the swelling. C. Position the child in a supine position with legs elevated. D. Assess the client's airway and breathing rate.

Correct Answer is D

Explanation

A. Applying topical diphenhydramine may help with local itching but is not the priority in a child with a known allergy to insect stings.

B. A cool pack can reduce swelling but is not the priority action if an allergic reaction is suspected.

C. Positioning the child with legs elevated is appropriate if there are signs of shock but does not address the immediate risk of airway compromise.

D. Assessing the client's airway and breathing rate is the priority because a child with a known allergy to insect stings is at risk for anaphylaxis, which can cause airway obstruction and respiratory distress. Early recognition and intervention are critical.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A 17-year-old well-female has come to the clinic to get a rubella immunization that is required by the college she plans to attend. Before administering this immunization, the client should have which screening or test?

Correct Answer is C

Explanation

A child allergic to insect stings presents to the school nurse stating, "A bee stung me on the playground." Which action by the school nurse should be prioritized?

Correct Answer is D

Explanation

A nurse has developed a plan of care for a family whose 7-year-old has been experiencing enuresis. Which of the following statements by the parents indicates that further teaching is needed?

A school-age client with asthma has been monitoring their daily peak expiratory flow rates(PEFR). The client's mother calls the clinic to report that the PEFR was at 45% of their personal best. Which guidance should the nurse provide to the mother?

An infant is admitted to the unit with a diagnosis of bladder exstrophy. What should the nurse prioritize when caring for a client with this condition?

The nurse is explaining to parents that the preschooler's developmental task is focused on the development of initiative rather than guilt. What is a priority intervention the nurse might recommend for parents of preschoolers to stimulate initiative?

A nurse is caring for a 4-year-old who was admitted with acute diarrhea and dehydration. Which finding indicates that oral rehydration therapy has been effective?

A 10-year-old client is experiencing acute renal failure from long-term kidney disease. The nurse is preparing to administer intravenous (IV) fluid. Which action is appropriate when caring for this client?

A nurse is admitting a pediatric client to the unit who has leukemia. Which client should the nurse place in the same room with this child?