A 7-year-old female child admitted to pre-op for scheduled surgery. Focused assessment completed. Lung sounds are clear to auscultation (CTA), heart sounds clear with normal sinus rhythm, skin clear with no breakdown.

Abdomen soft with bowel sounds heard in all 4 quadrants.

A feeding tube is present on the abdomen

Site is clean and clear.

Consents for surgery signed by parent at preadmission visit.

Peripheral IV (PIV) 22 gauge inserted in right forearm with assistance from another nurse.

Cried throughout procedure.

Comforted by parent and use of touch music.

IV fluids at 75 mL/hr started.

Client transported to operating room (OR) and The nurse is developing the plan of care for the child. To provide atraumatic care for this child post-operatively, what will be the priority?

Pain assessments

Antibiotics

Occupational therapy

Wound care

Physical therapy

Answer and Explanation

The Correct Answer is A

Assessing and managing pain is a crucial aspect of providing atraumatic care for any post-operative patient, including a child. The child cried throughout the procedure and will likely experience discomfort and pain after the surgery. It is important to assess the child's pain levels regularly using appropriate pain assessment tools and provide appropriate pain management interventions to ensure their comfort and well-being.

While antibiotics may be prescribed if there is a surgical site infection or specific indications for their use, it is not mentioned as a priority in this scenario. The focus is on providing atraumatic care post-operatively, and pain assessment takes precedence.

Occupational therapy, physical therapy, and wound care are important components of the child's overall care, but they may not be the immediate priority post-operatively.

These interventions can be incorporated into the plan of care as needed, but addressing pain is of utmost importance in the immediate post-operative period.

Nursing Test Bank

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Free Nursing Study Resources

Correct Answer is ["A","B","D"]

Explanation

A) Correct- Weighing the client and reporting any weight gain is a routine measurement that can be safely performed by the UAP. Weight gain can be an important indicator of fluid retention, a common issue in Cushing's syndrome.
B) Correct- Reporting any client complaints of pain or discomfort is important for monitoring the client's well-being and promptly addressing any potential issues.
C) Incorrect- Evaluating the client for sleep disturbances involves assessing the client's sleep patterns, quality, and potential disruptions. This requires nursing judgment and a deeper understanding of the client's condition and potential contributing factors, so it's not appropriate to delegate this task to the UAP.
D) Correct- Noting and reporting the client's food and liquid intake during meals and snacks is part of monitoring the client's nutritional status, which is an appropriate task for the UAP.
E) Incorrect- Assessing the client for weakness and fatigue involves a more comprehensive evaluation of the client's physical and physiological status, which requires nursing expertise. The nurse should directly assess and interpret these symptoms in the context of Cushing's syndrome to provide appropriate interventions.

A. Have the client vocalize the instructions provided. B. Provide written instructions for eye drop administration. C. Speak clearly and face the client for lip reading. D. Ensure that someone will stay with the client for 24 hours.

Correct Answer is A

Explanation

The correct answer ischoice A.

Choice A rationale:

Having the client vocalize the instructions provided ensures that they have understood the information correctly.This method allows the nurse to confirm comprehension and clarify any misunderstandings.

Choice B rationale:

Providing written instructions for eye drop administration is helpful but does not ensure that the client understands the instructions.It is a good supplementary measure but should not be the sole method of communication.

Choice C rationale:

Speaking clearly and facing the client for lip reading is important, especially for clients with hearing impairments.However, it does not guarantee that the client has understood the instructions.

Choice D rationale:

Ensuring that someone will stay with the client for 24 hours is a good safety measure but does not directly address the client’s understanding of the discharge instructions.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is managing the care of a client with Cushing's syndrome. Which intervention(s) should the nurse delegate to the unlicensed assistive personnel (UAP)? (Select all that apply.)

Correct Answer is ["A","B","D"]

Explanation

An older woman who has difficulty hearing is being discharged from day surgery following a cataract extraction and lens implantation. Which intervention is most important for the nurse to implement to help ensure the client's compliance with self-care?

Correct Answer is A

Explanation

The nurse is providing care to a client having surgery to repair a retinal detachment to the left eye. Which intervention should the nurse implement during the postoperative period?

An older client comes to the clinic with a family member. When the nurse attempts to take the client's health history, the client does not respond to questions in a clear manner. Which action should the nurse implement first?

Patient Data What other treatments might be helpful for this client? Select all that apply.

When the nurse enters the room of a male client who was admitted for a fractured femur, his cardiac monitor displays a normal sinus rhythm (NSR), but he has no spontaneous respirations and his carotid pulse is not palpable. Which intervention should the nurse implement?

When performing suctioning for a client with a tracheostomy, which action should the nurse include?

When the parents of a 6-year-old boy with a brain tumor are told that his condition is terminal, the mother shouts at the father, "This is your fault! It never would have happened if we had sought treatment sooner!" Which intervention is best for the nurse to implement?

The nurse is preparing a client who had a below-the-knee (BKA) amputation for discharge to home. Which recommendation(s) should the nurse provide this client? (Select all that apply.)

The nurse is administering multiple prescribed vaccines to a toddler. Which strategy should the nurse prioritize to reduce the duration of pain?