A client is transferred to the pediatric unit after repair of a cleft lip. The child has a Logan bow in place over the suture line and has elbow restraints applied to both arms. Which nursing intervention should take priority in her postoperative care plan?

Encourage attachment.

Minimize crying.

Restrict oral intake.

Initiate range of motion.

Answer and Explanation

The Correct Answer is B

Minimize crying.

Choice A rationale:

Encouraging attachment might be important for the child's emotional well-being, but in the immediate postoperative period after cleft lip repair, minimizing crying takes priority. Crying can place stress on the suture line and disrupt the healing process.

Choice B rationale:

Minimizing crying is crucial to prevent tension on the suture line and ensure proper healing of the cleft lip repair. Excessive crying can lead to increased pressure on the surgical site and potential complications. Elbow restraints are applied to prevent the child from touching the surgical site, so minimizing crying helps to maintain the effectiveness of these restraints.

Choice C rationale:

Restricting oral intake is not a priority in this case. While it's important to ensure the child doesn't consume anything that might harm the surgical site, it's not the highest priority action compared to preventing tension on the suture line.

Choice D rationale:

Initiating range of motion is not the priority postoperative intervention for a cleft lip repair. The primary concern at this stage is to prevent disruption of the surgical site and ensure proper healing, making minimizing crying a higher priority.

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Correct Answer is C

Explanation

Choice A rationale:

Misdiagnosis is unlikely since the glucose levels are improving, indicating a valid diagnosis.

Choice B rationale:

Insulin-producing cells don't regenerate in substantial amounts to normalize glucose levels within a month. This process takes longer.

Choice C rationale:

This choice correctly identifies the situation as a temporary improvement due to the remaining insulin-producing cells functioning better temporarily.

Choice D rationale:

Complete recovery is not likely in such a short time frame.

A. Give the patient a laxative. B. Obtain an order for ibuprofen for the patient. C. Remove all beverages from the patient's bedside. D. Provide a heating pad for the patient.

Correct Answer is C

Explanation

Remove all beverages from the patient's bedside.

Choice A rationale:

Giving the patient a laxative is inappropriate and unnecessary in the context of a ruptured appendix. The focus should be on preparing the patient for surgery and managing the acute condition.

Choice B rationale:

Administering ibuprofen should be avoided as it can mask symptoms and potentially worsen the patient's condition by masking signs of inflammation or infection. This delay in appropriate care could lead to complications.

Choice C rationale:

Removing all beverages from the patient's bedside is essential. NPO (nothing by mouth) status is typically maintained for patients with suspected appendicitis or other surgical conditions to prevent potential aspiration in case surgery is required.

Choice D rationale:

Providing a heating pad is contraindicated in cases of suspected appendicitis or any acute abdominal condition. Heat can worsen inflammation and potentially cause the appendix to rupture, leading to more severe complications.

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A client is transferred to the pediatric unit after repair of a cleft lip. The child has a Logan bow in place over the suture line and has elbow restraints applied to both arms. Which nursing intervention should take priority in her postoperative care plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A patient newly diagnosed with insulin-dependent diabetes mellitus comes to the clinic one month after diagnosis. The mother tells the nurse, "My child is getting better. The glucose levels are almost normal and my child requires less insulin.". What is the most appropriate response by the nurse?

Correct Answer is C

Explanation

A 7-year-old patient has been admitted to the hospital with a ruptured appendix. Which action should the nurse take while awaiting surgery?

Correct Answer is C

Explanation

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