A nurse is planning care for an adolescent following repair of Meckel Diverticulum.Which of the following actions should the nurse include in the plan of care?
Administer total parenteral nutrition
Initiate long term antibiotic therapy
Maintain an Ng tube for decompression
Teach the client about ostomy care
The Correct Answer is C
Choice A rationale
Administering total parenteral nutrition is not typically necessary following repair of Meckel’s Diverticulum. The patient is usually able to resume normal eating habits after surgery.
Choice B rationale
Long-term antibiotic therapy is not typically required following repair of Meckel’s Diverticulum. Antibiotics may be used in the short term to prevent infection, but long-term use is not usually necessary.
Choice C rationale
Maintaining an NG tube for decompression is a common part of care following abdominal surgery, including repair of Meckel’s Diverticulum. This helps to relieve pressure and allow the intestines to rest and heal.
Choice D rationale
Teaching the client about ostomy care is not typically necessary following repair of Meckel’s Diverticulum, as an ostomy is not usually required.
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Related Questions
Correct Answer is D
Explanation
The correct answer is D. Have the child flex his head when securing the ties.
Explanation:
When securing tracheostomy ties, flexing the head helps ensure the ties are snug but not too tight. This minimizes the risk of accidental dislodgement while allowing proper airway support.
Why the other options are incorrect:
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A. Use clean technique to change the tracheostomy tube – Incorrect. Sterile technique is required when changing the tracheostomy tube to prevent infection, especially in pediatric clients.
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B. Clean around the stoma with full-strength hydrogen peroxide – Incorrect. Diluted hydrogen peroxide or saline is recommended to avoid tissue irritation. Full-strength hydrogen peroxide can damage delicate skin around the stoma.
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C. Place the child in Trendelenburg position when performing care – Incorrect. The Trendelenburg position (head down, feet up) is not used for tracheostomy care and can increase the risk of aspiration or breathing difficulties.
Correct Answer is C
Explanation
The correct answer is choice c. Sunken anterior fontanel.
Choice A rationale:
A heart rate of 162/min in a 2-month-old infant can be within the upper range of normal, especially if the infant is crying or agitated. While it is important to monitor, it is not the most critical finding in this context.
Choice B rationale:
A negative doll’s eye reflex (oculocephalic reflex) can indicate neurological issues, but it is not directly related to heart failure or the administration of furosemide.
Choice C rationale:
A sunken anterior fontanel indicates dehydration, which is a critical concern for an infant receiving furosemide, a diuretic that can lead to significant fluid loss. Dehydration can exacerbate heart failure and lead to severe complications.
Choice D rationale:
A potassium level of 5.1 mEq/L is slightly elevated but not immediately life-threatening. It requires monitoring and potential intervention but is not the most urgent issue compared to dehydration.
Monitoring for dehydration is crucial in infants on diuretics like furosemide, making the sunken anterior fontanel the priority finding.
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