A child diagnosed with Hirschsprung's disease is scheduled for surgery. Which of the following actions should the nurse include in the preoperative care for this child? (Select All that Apply.)
Measure abdominal girth
Teach the child deep breathing exercises
Assess the child's bowel function with characteristics of stool
Administer isotonic enema to evacuate bowel
Administer an antibiotic as per order
Restrict the child's fluid intake
Assess vomiting
Correct Answer : A,C,E,G
A. Measure abdominal girth – Correct. Measuring abdominal girth helps monitor for signs of obstruction, which is common in Hirschsprung’s disease due to the absence of ganglion cells in the colon.
B. Teach the child deep breathing exercises – Incorrect. Deep breathing exercises are not typically taught to infants or young children undergoing surgery for Hirschsprung’s disease.
C. Assess the child's bowel function with characteristics of stool – Correct. Assessing stool patterns is important since Hirschsprung’s disease is characterized by an absence of peristalsis in the affected bowel.
D. Administer isotonic enema to evacuate bowel – Incorrect. Enemas are contraindicated in Hirschsprung’s disease as they can lead to bowel perforation.
E. Administer an antibiotic as per order – Correct. Preoperative antibiotics are given to prevent infection.
F. Restrict the child's fluid intake – Incorrect. Fluid restriction is not necessary and may worsen dehydration, especially if the child has vomiting or diarrhea.
G. Assess vomiting – Correct. Vomiting can indicate worsening obstruction or enterocolitis, a serious complication of Hirschsprung’s disease.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["70"]
Explanation
The nurse should withhold digoxin if the child's apical heart rate is less than 70 beats per minute because digoxin slows the conduction of electrical signals in the heart and increases the force of cardiac contraction. While this helps to treat conditions like heart failure and arrhythmias, it can also lead to bradycardia. Administering digoxin when the heart rate is already too low increases the risk of adverse effects like severe bradycardia or even cardiac arrest.
Correct Answer is D
Explanation
A. Treat bacterial infections – Incorrect. N-acetylcysteine is not an antibiotic.
B. Promote coughing and clear secretions – Incorrect. This describes its use in cystic fibrosis as a mucolytic, not in acetaminophen toxicity.
C. Reduce pain and fever – Incorrect. Acetaminophen, not N-acetylcysteine, is used for pain and fever.
D. Prevent liver damage – Correct. N-acetylcysteine replenishes glutathione stores, which helps detoxify acetaminophen metabolites that cause hepatotoxicity.
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