A nurse is assisting with the plan of care for a child who is 12 hr postoperative following a ruptured appendix with peritonitis. Which of the following actions should the nurse include in the plan of care?
Give pain medications on a schedule.
Initiate contact isolation.
Offer clear liquids.
Maintain strict bed rest.
The Correct Answer is A
Choice A reason:
Providing pain medication on a schedule is important for managing pain and ensuring the child's comfort, especially after a surgery involving peritonitis.
Choice B reason:
Contact isolation is not typically indicated for a child postoperative for appendicitis unless there is a specific infectious concern. It is not a routine intervention.
Choice C reason:
Offering clear liquids may be appropriate depending on the child's individual recovery and surgeon's orders. However, this should be determined on an individual basis and is not a standard postoperative intervention.
Choice D reason:
Maintaining strict bed rest may not be necessary for all children postoperative for appendicitis. Early mobilization and ambulation are often encouraged to promote recovery.
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Correct Answer is D
Explanation
Choice A reason:
Discontinuing antibiotics when the fever has resolved is not an appropriate instruction for a child with infective endocarditis. The full course of antibiotics should be completed.
Choice B reason:
While antibiotics can have side effects, splinter hemorrhages under the child's nails are not a common side effect of antibiotic use for infective endocarditis.
Choice C reason:
Obtaining prophylactic antibiotics for family members is not a standard practice for infective endocarditis.
Choice D reason:
This statement is correct. Antibiotics are needed prior to certain dental procedures for children with infective endocarditis to prevent bacterial endocarditis.
Correct Answer is B
Explanation
Choice A reason:
A blood glucose level of 220 mg/dL is elevated and should be addressed, but it may not be an immediate priority compared to the presence of Kussmaul respirations.
Choice B reason.
Correct. Kussmaul respirations are a sign of diabetic ketoacidosis (DKA), a severe complication of diabetes. This requires immediate attention and intervention.
Choice C reason:
Vomiting is a concerning symptom, but it may not be as immediately life-threatening as Kussmaul respirations.
Choice D reason:
Frequent urination is a common symptom of diabetes, but it may not require immediate intervention unless it is accompanied by other severe symptoms.
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