Nokea
A nurse is planning care for a school-age child who is 4 hr postoperative following appendicitis. Which of the following actions should the nurse include in the plan of care?
- A. Apply a warm compress to the operative site once daily
- B. Administer analgesics on a scheduled basis for the first 24 hr
- C. Give cromolyn nebulized solution every 8 hr.
- D. Offer small amounts of clear liquids 6 hr following surgery
Correct Answer: B
Rationale: The correct answer is B: Administer analgesics on a scheduled basis for the first 24 hr. Postoperative pain management is crucial to ensure the child's comfort and facilitate recovery. Administering analgesics on a scheduled basis helps maintain a consistent level of pain relief and prevents breakthrough pain. This approach is especially important in the immediate postoperative period when pain levels are typically higher. Options A, C, and D are incorrect because applying a warm compress, giving cromolyn nebulized solution, and offering clear liquids are not primary interventions for postoperative pain management in this scenario. Option D specifically is not recommended as clear liquids are usually introduced gradually to prevent complications. Providing analgesics on a scheduled basis is the best course of action to address the child's immediate postoperative pain effectively.
You may also like to solve these questions
A nurse is preparing to initiate intravenous fluids via infusion pump for a client. Which of the following actions should the nurse take?
- A. Obtain a surge protector that can accommodate the pump and several other appliances
- B. Verify that the extension cord for the pump is ungrounded
- C. Report the pump has a frayed cord and proceed with the infusion
- D. Check the expiration date on the safety inspection sticker of the pump
Correct Answer: D
Rationale: The correct answer is D: Check the expiration date on the safety inspection sticker of the pump. This is crucial for ensuring the safety and efficacy of the pump. Checking the expiration date ensures that the pump has been recently inspected and is functioning properly, reducing the risk of malfunctions.
A: Obtaining a surge protector is important for electrical safety, but it is not directly related to the specific task of initiating intravenous fluids via an infusion pump.
B: Verifying that the extension cord is ungrounded is unsafe as it increases the risk of electrical hazards.
C: Reporting a frayed cord is essential for patient safety, but proceeding with the infusion without addressing the issue is dangerous.
E, F, G: No information provided.
A home health nurse is planning care for a client who has Alzheimer's disease. Which of the following actions should the nurse include in the plan of care?
- A. Replace the carpet with hardwood floors
- B. Encourage physical activity prior to bedtime
- C. Wear clothing with zippers instead of buttons
- D. Place locks at the tops of exterior doors
Correct Answer: D
Rationale: The correct answer is D: Place locks at the tops of exterior doors. This is important because individuals with Alzheimer's disease may wander and become lost. Placing locks at the tops of exterior doors can help prevent the client from leaving the home unsupervised and potentially getting lost or injured.
A: Replacing the carpet with hardwood floors is not directly related to the safety of the client with Alzheimer's disease.
B: Encouraging physical activity prior to bedtime may actually disrupt sleep patterns for individuals with Alzheimer's disease.
C: Wearing clothing with zippers instead of buttons may not significantly impact the client's safety.
Overall, option D is the most appropriate choice to ensure the safety and well-being of the client with Alzheimer's disease.
A nurse is assessing a client who is postoperative and has a history of pulmonary embolism. Which of the following findings is the priority for the nurse to report to the provider?
- A. Tachycardia
- B. Dry cough
- C. Dyspnea
- D. Hypotension
Correct Answer: C
Rationale: The correct answer is C: Dyspnea. Dyspnea in a postoperative client with a history of pulmonary embolism indicates a potential respiratory complication, which could be life-threatening. The priority is to report this finding to the provider for prompt evaluation and intervention to prevent further complications. Tachycardia (A) and hypotension (D) may also be concerning but dyspnea takes precedence due to its association with pulmonary embolism. A dry cough (B) may be a common postoperative symptom and not necessarily urgent.
A nurse is caring for a client who is receiving radiation therapy and is experiencing anorexia. Which of the following actions should the nurse take?
- A. Encourage the client to drink low-protein supplements
- B. Tell the client to drink two glasses of water with meals
- C. Serve the client's largest meal in the evening
- D. Provide the client with cold foods rather than hot foods
Correct Answer: D
Rationale: The correct answer is D: Provide the client with cold foods rather than hot foods. Cold foods may be more appealing to a client experiencing anorexia due to radiation therapy, as they often have less strong smells and flavors that can trigger nausea. Cold foods can also help soothe any oral mucositis or mouth sores that may be present. Encouraging the client to eat cold foods can help increase their overall intake and provide necessary nutrients.
Choice A is incorrect because low-protein supplements may not be sufficient in providing necessary nutrients for the client. Choice B is incorrect as simply drinking water with meals may not address the underlying issue of anorexia. Choice C is incorrect as there is no evidence to suggest that serving the largest meal in the evening will improve the client's appetite.
The nurse is reviewing the client's medical record. Select 4 findings that indicate a potential prenatal complication.
- A. Urine protein
- B. Fetal activity
- C. Blood pressure
- D. Urine ketones
- E. Respiratory rate
- F. Report of headache
- G. Gravida/parity
Correct Answer: A, B, C, F
Rationale: The correct answer includes findings that are indicative of potential prenatal complications.
A: Urine protein can indicate preeclampsia, a serious condition in pregnancy.
B: Fetal activity changes may suggest fetal distress or growth restriction.
C: Blood pressure changes can indicate hypertension or preeclampsia.
F: Headache can be a symptom of preeclampsia or other serious conditions.
Choices D, E, and G are not typically associated with prenatal complications. D: Urine ketones may indicate dehydration but not necessarily a prenatal complication. E: Respiratory rate is not directly related to prenatal complications. G: Gravida/parity information is important for obstetric history but not directly indicative of current prenatal complications.