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. This is essential postoperatively to manage pain effectively and improve the child's comfort level. Pain management is crucial in the early stages following surgery to prevent complications and aid in the child's recovery. Applying a warm compress (choice A) may not be appropriate for the surgical site and could potentially cause harm. Giving cromolyn nebulized solution (choice C) is not indicated for pain management postoperatively. Offering clear liquids (choice D) too soon after surgery could increase the risk of complications such as nausea, vomiting, or aspiration.
You may also like to solve these questions
A nurse is assessing a child who has bacterial pneumonia. Which of the following manifestations should the nurse expect?
- A. Steatorrhea
- B. Fever
- C. Drooling
- D. Tinnitus
Correct Answer: B
Rationale: The correct answer is B: Fever. In bacterial pneumonia, the body's immune response leads to fever as a common manifestation due to the infection. This is because the body is trying to fight off the bacterial invasion. Steatorrhea (A) is not typically associated with bacterial pneumonia. Drooling (C) is more commonly seen in conditions affecting the mouth or throat. Tinnitus (D) is a symptom related to the ears and is not typically associated with pneumonia. Therefore, the presence of fever is the most relevant sign in a child with bacterial pneumonia.
A nurse is providing teaching about home safety to the adult child of an older adult client who is postoperative following knee replacement surgery. Which of the following instructions should the nurse include?
- A. Encourage the client to avoid wearing shoes at home.
- B. Place a throw rug over electrical cords.
- C. Mark the edges of the doorway to the house with tape.
- D. Ensure that area rugs have rubber backs.
Correct Answer: D
Rationale: The correct answer is D: Ensure that area rugs have rubber backs. This instruction is important because rugs with rubber backs are less likely to slip, reducing the risk of falls for the older adult post knee replacement surgery. Choice A is incorrect as wearing shoes at home can increase the risk of falls due to slippery surfaces. Choice B is incorrect as placing a throw rug over electrical cords can create a tripping hazard. Choice C is incorrect as marking the edges of the doorway with tape does not address the risk of tripping over rugs.
A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take?
- A. Perform the procedure prior to meals.
- B. Hold hand flat to perform percussions on the child.
- C. Administer a bronchodilator after the procedure.
- D. Perform the procedure twice each day.
Correct Answer: A
Rationale: The correct answer is A: Perform the procedure prior to meals. Postural drainage helps clear mucus from the lungs. Performing it before meals prevents aspiration since the child's stomach will be empty. This timing also maximizes the effectiveness of postural drainage by clearing the airways before meals, which can help improve breathing.
B: Holding hand flat for percussions is incorrect as cupped hands are used to provide effective percussions.
C: Administering a bronchodilator after the procedure does not relate to the timing of postural drainage.
D: Performing the procedure twice each day is not specific to the timing of postural drainage.
A nurse is caring for an infant who has diaper dermatitis. Which of the following actions should the nurse take?
- A. Apply talcum powder to the irritated area.
- B. Wipe stool from the skin using store-bought baby wipes.
- C. Apply zinc oxide ointment to the irritated area.
- D. Wipe urine from the skin using a cool cloth.
Correct Answer: C
Rationale: The correct answer is C: Apply zinc oxide ointment to the irritated area. Zinc oxide ointment provides a protective barrier on the skin, helping to soothe and heal diaper dermatitis. It also helps to keep moisture away from the irritated skin, promoting healing.
Incorrect options:
A: Applying talcum powder can further irritate the skin as it can be abrasive.
B: Store-bought baby wipes may contain chemicals or fragrances that can worsen the condition.
D: Wiping urine with a cool cloth is a good practice, but it does not address the issue of diaper dermatitis.
Overall, option C is the best choice as it directly addresses the diaper dermatitis by providing a protective barrier and promoting healing.
A nurse is planning postoperative care for an adolescent following scoliosis repair with spinal instrumentation. Which of the following actions should the nurse include in the plan of care?
- A. Maintain the head of the bed at a 30° angle.
- B. Offer sips of water due to having surgery.
- C. Log roll the adolescent every 2 hours.
- D. Assist the adolescent to ambulate 12 hours following surgery.
Correct Answer: C
Rationale: The correct answer is C: Log roll the adolescent every 2 hours. This is important to prevent pressure ulcers and maintain spinal alignment post-surgery. Log-rolling involves turning the patient as a unit to avoid twisting the spine. Maintaining the head of the bed at a 30° angle (choice A) is important for respiratory function but not specific to spinal surgery. Offering sips of water (choice B) is generally appropriate after surgery but not specific to spinal instrumentation. Assisting the adolescent to ambulate (choice D) should be done gradually and with caution, typically starting with sitting on the bedside first, rather than a fixed time frame like 12 hours post-surgery.