A fourteen-year-old girl has returned to the nursing unit after undergoing an appendectomy. To help relieve pain and facilitate drainage, the nurse should place her in what position?
Semi-Fowler's
Supine
Prone
Trendelenburg
The Correct Answer is A
Choice A reason: This is correct because the semi-Fowler's position, which is a 30 to 45 degree angle of the head of the bed, allows for optimal drainage of the surgical site and reduces the pressure on the incision. It also helps the girl breathe easier and prevents aspiration.
Choice B reason: This is incorrect because the supine position, which is lying flat on the back, can increase the pain and discomfort of the girl after the appendectomy. It can also impair the drainage of the surgical site and increase the risk of infection.
Choice C reason: This is incorrect because the prone position, which is lying on the stomach, can cause more pain and pressure on the incision site. It can also interfere with the drainage of the surgical site and increase the risk of infection.
Choice D reason: This is incorrect because the Trendelenburg position, which is a head-down tilt of the bed, can increase the intra-abdominal pressure and cause more pain and discomfort for the girl. It can also impair the venous return and cause hypotension.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: Increased stroke volume is not a correct answer as it means that the heart pumps more blood with each contraction. This would result in increased blood pressure and perfusion, not cool extremities, weak pulses, and low urine output.
Choice B reason: Cardiac arrhythmia is not a correct answer as it means that the heart beats irregularly or abnormally. This can cause palpitations, chest pain, or fainting, but not necessarily cool extremities, weak pulses, and low urine output.
Choice C reason: Decreased cardiac output is a correct answer as it means that the heart pumps less blood than the body needs. This can result from a ventricular septal defect, which causes blood to shunt from the left ventricle to the right ventricle, reducing the amount of oxygenated blood that reaches the tissues. This can cause cool extremities, weak pulses, and low urine output, as well as fatigue, poor growth, and shortness of breath.
Choice D reason: Cyanosis is not a correct answer as it means that the skin, lips, or nails turn blue due to low oxygen levels in the blood. This can occur in some cases of ventricular septal defect, especially if there is pulmonary hypertension or a reversal of the shunt. However, cyanosis is not a direct cause of cool extremities, weak pulses, and low urine output.
Correct Answer is A
Explanation
Choice A reason: This statement is correct, as standard precautions are the minimum level of infection control practices that should be applied to all patients, regardless of their diagnosis or presumed infection status. Standard precautions include hand hygiene, use of personal protective equipment (PPE), safe handling of sharps and contaminated items, and environmental cleaning. Standard precautions are sufficient for most patients with HIV, unless they have other infections that require additional precautions.
Choice B reason: This statement is incorrect, as droplet precautions are not required for patients with HIV, unless they have other infections that are transmitted by respiratory droplets, such as influenza, pertussis, or meningitis. Droplet precautions include wearing a surgical mask when within 3 feet of the patient, placing the patient in a private room or cohorting with other patients with the same infection, and limiting the movement of the patient outside the room.
Choice C reason: This statement is incorrect, as contact precautions are not required for patients with HIV, unless they have other infections that are transmitted by direct or indirect contact, such as Clostridioides difficile, scabies, or herpes simplex virus. Contact precautions include wearing gloves and gowns when entering the patient's room, placing the patient in a private room or cohorting with other patients with the same infection, and dedicating patient-care equipment to the patient or disinfecting it before use on another patient.
Choice D reason: This statement is incorrect, as airborne precautions are not required for patients with HIV, unless they have other infections that are transmitted by airborne particles, such as tuberculosis, measles, or chickenpox. Airborne precautions include wearing a respirator or N95 mask when entering the patient's room, placing the patient in a negative-pressure isolation room with the door closed, and limiting the movement of the patient outside the room.
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