A nurse is planning care for an adolescent following the repair of the Meckel diverticulum. Which of the following actions should the nurse include in the plan of care?
Teach the client about ostomy care.
Administer total parenteral nutrition.
Initiate long-term antibiotic therapy.
Maintain an NG tube for decompression.
The Correct Answer is D
A. Teaching the client about ostomy care is unnecessary because surgical repair of Meckel diverticulum does not typically require an ostomy.
B. Administering total parenteral nutrition (TPN) is not routinely required postoperatively unless there are significant complications affecting digestion.
C. Initiating long-term antibiotic therapy is not standard post-surgical care for Meckel diverticulum repair; antibiotics are usually given short-term to prevent infection.
D. Maintaining an NG tube for decompression is appropriate because postoperative bowel rest is needed to prevent distension and reduce the risk of complications such as ileus.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Renal calculi (kidney stones) are not directly related to fractures of the lower
extremities. They form in the kidneys and can cause pain and other symptoms when they pass into the urinary tract.
B. Osteomyelitis is a bone infection that can occur as a complication of fractures, but it typically develops over a longer period of time than the first 24 hours after the injury.
C. This is the correct answer. Compartment syndrome is a serious complication of fractures that can occur within the first 24 hours after injury. It is characterized by
increased pressure within a muscle compartment, leading to reduced blood flow, nerve compression, and tissue damage.
D. Volkmann ischemic contracture is a complication that can occur if there is prolonged or severe muscle ischemia (lack of blood flow) following a fracture. It is not typically a concern within the first 24 hours after the injury
Correct Answer is D
Explanation
- A: Tighten the screws on the halo device one-quarter turn every 48 hr.
- Rationale: This action is incorrect because the screws on a halo device should not be adjusted by the nurse. The screws are typically set and secured by a healthcare provider, and any adjustments can compromise the integrity of the device and the stability of the cervical spine.
- B: Assess the pin sites for infection once every other day.
- Rationale: While it is important to monitor the pin sites for signs of infection, doing so once every other day may not be sufficient. Pin sites should be assessed at least once per shift to ensure early detection and management of any potential infection.
- C: Encourage flexion and extension of the neck.
- Rationale: This action is contraindicated for a client with a halo vest. The purpose of the halo vest is to immobilize the cervical spine to promote healing. Encouraging neck movement could cause further injury or delay healing.
- D: Reposition the client using a turning sheet.
- Rationale: This is the correct action. Using a turning sheet helps to reposition the client safely and effectively without exerting unnecessary pressure on the cervical spine. It also aids in preventing pressure ulcers and promotes comfort for the client.
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