The nurse is caring for the patient who is 1-day status post splenectomy. The patient complains of pain of a 3 on inspiration. What would be the most appropriate priority nursing intervention for this patient?
Contact the surgeon to obtain orders for a nebulizer treatment from respiratory therapy.
Provide the patient with a heating pad alternated with a cold pack for incisional pain.
Medicate with opioids for pain and assist the patient to deep breathe, cough, and ambulate.
Contact the surgeon to request a chest x-ray and a laboratory draw for CBC with differential.
The Correct Answer is C
A. Contact the surgeon to obtain orders for a nebulizer treatment from respiratory therapy. A nebulizer is typically not the initial intervention for mild post-operative pain or mild respiratory discomfort due to pain with inspiration.
B. Provide the patient with a heating pad alternated with a cold pack for incisional pain. While heat or cold therapy can help with pain, opioid pain management with encouragement to perform deep breathing exercises is more effective for post-splenectomy patients.
C. Medicate with opioids for pain and assist the patient to deep breathe, cough, and ambulate. Pain management combined with encouraging deep breathing, coughing, and early ambulation helps prevent post-operative complications like atelectasis and pneumonia, which are common after abdominal surgeries.
D. Contact the surgeon to request a chest x-ray and a laboratory draw for CBC with differential. This intervention might be necessary if there were signs of infection or other complications, but mild pain with inspiration on the first day post-op does not typically warrant imaging or labs.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Cryoprecipitates: Cryoprecipitates contain fibrinogen, factor VIII, von Willebrand factor, and factor XIII, and are typically used for patients with specific factor deficiencies, such as hemophilia or fibrinogen deficiency, rather than general clotting disorders.
B. Frozen Packed Red Blood Cells (PRBCs): PRBCs are primarily used to treat anemia and to increase oxygen-carrying capacity, not to correct clotting factor deficiencies.
C. Fresh frozen plasma (FFP): Fresh frozen plasma (FFP) contains clotting factors and is administered to patients with clotting disorders to help manage bleeding by replenishing these factors.
D. Platelets: Platelets are administered to patients with thrombocytopenia or platelet dysfunction, not to replace clotting factors as needed in general clotting disorders.
Correct Answer is ["B","C","D","F","G"]
Explanation
A. Blood pressure: The blood pressure is within normal limits and does not indicate an acute issue in this context.
B. Skin assessment: The presence of pallor and bruising indicates potential anemia and thrombocytopenia, common in leukemia patients but concerning signs that need to be monitored.
C. Breath sounds: Rhonchi in the upper lobes suggest respiratory congestion or infection, which is dangerous in an immunocompromised child.
D. Oxygen saturation: A drop in oxygen saturation to 90% indicates impaired oxygenation, which could signify respiratory distress or worsening infection.
E. WBC count: Although WBC count is within the low-normal range, it does not independently indicate an immediate change in the child’s condition.
F. Retractions: Subcostal retractions indicate respiratory distress, which is critical to report as it could escalate quickly in a child.
G. Respiratory rate: The increased respiratory rate (from 22 to 30/min) reflects respiratory distress and may worsen if the infection progresses.
H. Hemoglobin: While low, the hemoglobin is not acutely life-threatening in this case and would not necessarily prompt urgent intervention without other symptoms.
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