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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason:
A maculopapular rash may be an allergic reaction to the antibiotic. While this should be reported, wheezing is a more urgent concern.
Choice B reason:
A headache may be a side effect of the antibiotic, but it is not as urgent as wheezing.
Choice C reason:
Wheezing can indicate a potential serious allergic reaction or anaphylaxis to the antibiotic. This is the priority finding to report to the provider.
Choice D reason:
An increased pulse may be a side effect of the antibiotic, but it is not as urgent as wheezing.
Correct Answer is D
Explanation
Choice A reason:
Taping the wire to the palm of the hand can be uncomfortable for the child and may interfere with blood flow.
Choice B reason:
Warming the skin prior to probe placement is not a standard practice for pulse oximetry monitoring.
Choice C reason:
Applying the sensor to the index fingernail is not a recommended site for pulse oximetry monitoring in children.
Choice D reason:
Repositioning the probe every 2 hours helps to prevent skin breakdown and ensures accurate readings over time. This is a standard practice in pulse oximetry monitoring.
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