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.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: This is the correct choice. Letting the child hear the sounds of an ECG monitor can help reduce anxiety and fear of the unknown. It can also help the child understand what to expect during the surgery and recovery.
Choice B reason: This is not a good choice. Avoiding mentioning postoperative discomfort and interventions can create unrealistic expectations and mistrust. The nurse should provide honest and age-appropriate information about the surgery and the possible complications and pain management.
Choice C reason: This is not a good choice. Explaining that an endotracheal tube will not be needed if the surgery goes well can imply that the surgery might not go well and cause unnecessary worry. The nurse should explain that an endotracheal tube is a common device that helps the child breathe during and after the surgery and that it will be removed as soon as possible.
Choice D reason: This is not a good choice. Unfamiliar equipment should be shown and explained to the child and the family in a simple and reassuring way. This can help them become familiar with the equipment and reduce their fear and anxiety.
Correct Answer is C
Explanation
Choice A reason: This statement is incorrect, as sodium excess is not likely to cause the symptoms of poor skin turgor, weight loss, irritability, and tachycardia in an infant. Sodium excess, or hypernatremia, is a condition where the blood sodium level is too high, which can result from excessive intake or loss of water. The symptoms of sodium excess may include thirst, dry mouth, confusion, seizures, or coma.
Choice B reason: This statement is incorrect, as overhydration is not likely to cause the symptoms of poor skin turgor, weight loss, irritability, and tachycardia in an infant. Overhydration, or hypervolemia, is a condition where the body has too much fluid, which can result from excessive intake or retention of water. The symptoms of overhydration may include edema, weight gain, shortness of breath, or crackles in the lungs.
Choice C reason: This statement is correct, as dehydration is the most likely cause of the symptoms of poor skin turgor, weight loss, irritability, and tachycardia in an infant. Dehydration is a condition where the body loses more fluid than it takes in, which can result from vomiting, diarrhea, fever, or inadequate intake of water. The symptoms of dehydration may include dry skin, sunken eyes, decreased urine output, or lethargy.
Choice D reason: This statement is incorrect, as calcium excess is not likely to cause the symptoms of poor skin turgor, weight loss, irritability, and tachycardia in an infant. Calcium excess, or hypercalcemia, is a condition where the blood calcium level is too high, which can result from hyperparathyroidism, malignancy, or excessive intake of vitamin D or calcium. The symptoms of calcium excess may include nausea, constipation, muscle weakness, or kidney stones.
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