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.
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Related Questions
Correct Answer is D
Explanation
A. Have the child eat a high-protein diet. There is no specific requirement for a high-protein diet to manage sickle cell disease. Hydration is more critical in crisis prevention.
B. Monitor the child's temperature twice per day. While monitoring for infection is essential, this is not the most important discharge instruction to prevent crises.
C. Restrict outdoor play activity. While strenuous exercise should be avoided, activity restriction is unnecessary as long as the child stays hydrated and avoids extreme conditions.
D. Encourage the child to increase his fluid intake. Increased fluid intake helps prevent sickling by reducing blood viscosity, which is essential in preventing future crises.
Correct Answer is B
Explanation
A. Thyroid disease: While some thyroid diseases may indirectly contribute to anemia, thyroid disease itself does not directly cause low hemoglobin and hematocrit.
B. Anemia: Low hemoglobin and hematocrit levels indicate anemia, which can be caused by various factors, including blood loss, iron deficiency, or chronic disease.
C. Acute bronchitis: Acute bronchitis typically affects respiratory function and does not directly cause a decrease in hemoglobin or hematocrit.
D. Hemochromatosis: Hemochromatosis is characterized by excess iron in the body, often resulting in elevated rather than decreased hemoglobin and hematocrit.
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