A nurse is contributing to the plan of care for an adolescent client following surgery for a ruptured appendix. Which of the following interventions should the nurse recommend to include in the plan?
Encourage the client to change positions every 4 hr.
Offer the client a clear liquid diet when fully alert.
Ensure that the client receives pain medication prior to ambulation.
Discontinue antibiotic therapy on the first postoperative day.
The Correct Answer is C
A. Encourage position change every 4 hr
Should be more frequent, typically every 2 hr to prevent complications.
B. Offer clear liquids when fully alert
Bowel sounds and flatus should be confirmed first to avoid ileus.
C. Ensure the client receives pain medication prior to ambulation.
Adequate pain control promotes mobility and reduces complications like atelectasis.
D. Discontinue antibiotics on first post-op day
Antibiotics are continued as per provider order, especially with ruptured appendix.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. "Examine your testicles after a warm shower.":
Warmth relaxes the scrotal sac, making it easier to palpate the testicles and detect abnormalities such as lumps or swelling.
B. "Palpate both testicles firmly with your fingertips.":
Testicles should be palpated gently, not firmly, to avoid discomfort and ensure accurate detection of changes.
C. "Apply a cool compress to the scrotum prior to examination.":
Cold causes scrotal contraction, making the exam more difficult.
D. "Perform the self-examination every 3 months.":
The recommended frequency is monthly, not every 3 months.
Correct Answer is B
Explanation
A. Sexual abuse is most often committed by a person who the child does not know.:
Most cases of sexual abuse are committed by someone the child knows and trusts, not strangers.
B. A child is at the highest risk for abuse from birth through 1 year of age.:
Infants are more vulnerable due to dependence and inability to verbalize or defend themselves.
C. Emotional abuse is the most common form of child maltreatment.:
Neglect, not emotional abuse, is the most common form of child maltreatment.
D. Physical neglect includes a failure to meet a child's needs for affection and attention.:
This describes emotional neglect, not physical neglect, which refers to food, shelter, hygiene, and medical care needs.
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