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 ["1610"]
Explanation
Solution:
- Convert ounces to milliliters (1 oz = 30 mL):
- Coffee: 8 oz × 30 mL = 240 mL
- Juice: 3 oz × 30 mL = 90 mL
- Soda: 12 oz × 30 mL = 360 mL
- Calculate water intake:
- Initial pitcher: 800 mL
- Remaining: 200 mL
- Water intake = 800 mL - 200 mL = 600 mL
- Calculate IV fluids intake:
- IV rate: 40 mL/hr
- Time: 8 hours
- IV fluids = 40 mL/hr × 8 hrs = 320 mL
- Total intake:
- 240 mL (coffee) + 90 mL (juice) + 360 mL (soda) + 600 mL (water) + 320 mL (IV) = 1610 mL
Answer: 1610 mL
Correct Answer is B
Explanation
A. WBCs: White blood cell counts may vary in multiple myeloma, but they are not typically increased; in fact, WBC counts can be low due to bone marrow crowding.
B. Calcium: Multiple myeloma often causes hypercalcemia because of increased bone breakdown, leading to the release of calcium into the bloodstream.
C. Absolute neutrophil count: The absolute neutrophil count may actually decrease as a result of bone marrow dysfunction, not increase.
D. Platelets: Platelet counts are often decreased in multiple myeloma due to bone marrow involvement, not increased.
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