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.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Fluid intake is usually restricted to prevent fluid overload, which can worsen edema and hypertension in acute glomerulonephritis.

B. Administering antibiotics may be necessary, especially if the condition is secondary to a streptococcal infection, which is a common cause of acute glomerulonephritis.

C. Rest is typically encouraged rather than frequent ambulation, as activity can exacerbate symptoms.

D. Daily weights, not weekly, are crucial for monitoring fluid balance in acute glomerulonephritis.

A. The client has urinary and bowel continence. B. The client is unable to tie their shoes. C. The client introduces their "friend" who is not visible to the nurse. D. The client speaks in 2-3 word sentences.

Correct Answer is D

Explanation

A. Urinary and bowel continence is expected by age 4, so this does not warrant further investigation.

B. Tying shoes is a skill typically developed later, around 5-6 years of age, so not being able to do so at age 4 is not concerning.

C. Having an imaginary friend is common in children around this age and is not a cause for concern.

D. Speaking in 2-3 word sentences is typical for a younger child, around 2 years of age. By age 4, a child should be able to speak in more complex sentences, so this finding warrants further investigation.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is planning care for a client who has acute glomerulonephritis. Which intervention should the nurse include in the plan when caring for this client?

Correct Answer is B

Explanation

A nurse is performing a developmental assessment on a 4-year-old client. What assessment finding would warrant further investigation?

Correct Answer is D

Explanation

While assessing a preadolescent client, the nurse notes curvature of the client's spine. Which statement by the parent supports this observation?

An adolescent presents to the clinic with extreme fatigue, fever, and body aches and is diagnosed with Epstein-Barr virus. What statement by the adolescent shows that discharge teaching was effective?

A nurse is closely monitoring a pediatric client following a tonsillectomy. Which finding would alert the nurse to a postoperative complication?

The nurse is reviewing the record of a pediatric client diagnosed with pyloric stenosis. Which assessment finding would the nurse expect to find in the electronic health record?

A 4-year-old client presents to the emergency department with drooling, agitation, and inability to cough. The nurse should recognize these findings are associated with which diagnosis?

The nurse is caring for a 14-year-old client diagnosed with celiac disease. The nurse knows that the client understands the diet instructions when they request which of the following meals?

The nurse is reviewing the treatment plan with the parents of a newborn with hypospadias. Which statement should the nurse include in the teaching when describing this disorder?