A nurse on a pediatric unit is caring for a preschooler who is postoperative following an appendectomy.
Complete the following sentence by using the lists of options.
The child is at risk for developing
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"A","dropdown-group-3":"C"}
- Postoperative ileus: Ileus is a common complication after abdominal surgery due to anesthesia, opioid use, and limited mobility. It presents as delayed return of bowel function, marked by absent bowel sounds and abdominal discomfort. In this case, the child has absent bowel sounds and increasing tenderness, supporting this risk.
- Atelectasis: Atelectasis generally presents with diminished breath sounds and hypoxia, not clear breath sounds. Although the child has shallow respirations and is refusing the incentive spirometer, there are no respiratory findings such as decreased oxygen saturation or adventitious breath sounds that support this condition currently.
- Peritonitis: Peritonitis would present with systemic symptoms like fever, severe abdominal pain, rebound tenderness, or signs of sepsis. The child has mild abdominal tenderness and stable vital signs, which do not indicate peritoneal inflammation at this time.
- Urinary retention: This would be characterized by lack of urination, bladder distension, or discomfort—none of which are noted in the scenario. The child’s urinary output and bladder status are not identified as concerns, making this diagnosis unlikely.
- Absent bowel sounds: This is a key clinical sign of ileus. After surgery, bowel activity should return gradually. Continued absence of sounds, especially along with abdominal tenderness, strongly indicates impaired gastrointestinal motility.
- Shallow respirations: While shallow breathing is often a contributing factor to respiratory complications, in the context of abdominal surgery, it also limits diaphragmatic movement, which can further suppress bowel activity and contribute to postoperative ileus.
- Clear breath sounds: This is a normal respiratory finding and does not support the presence of atelectasis or other pulmonary complications. It suggests that lung fields are adequately ventilated despite shallow breathing.
- Intact abdominal dressing: This is an expected postoperative finding and does not support a diagnosis of infection, wound complication, or ileus. It indicates proper surgical wound healing.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Trim the fat from red meat prior to cooking. Children with cystic fibrosis often have difficulty absorbing fats due to pancreatic insufficiency, but they actually need higher fat intake to meet their increased energy demands. Trimming fat is not necessary or recommended.
B. Provide a diet high in protein and calories. Children with cystic fibrosis require a high-calorie, high-protein diet to support growth, maintain weight, and compensate for the energy lost due to chronic lung infections and malabsorption.
C. Administer pancreatic enzymes 30 min after meals. Pancreatic enzymes should be given before or with meals and snacks to aid digestion. Giving them 30 minutes after a meal reduces their effectiveness.
D. Give the child hot foods to reduce the sense of fullness. There is no evidence to support using hot foods to manage fullness in cystic fibrosis. Instead, meals should be nutrient-dense and timed to optimize digestion and absorption.
Correct Answer is ["A","B","C","E","F"]
Explanation
A. Heart rate. The client’s heart rate decreased from 110/min on postpartum day 3 to 78/min on day 5, returning to normal resting range, which suggests improvement in systemic inflammation or infection, and better overall hemodynamic stability.
B. Temperature. The temperature has decreased from 38.6° C (101.5° F) to 37.1° C (98.9° F), which is within normal limits. This reduction is a key indicator of resolving infection or inflammation, especially considering the earlier febrile response.
C. Lochia. Lochia has improved from a moderate, foul-smelling, dark brown discharge to a small amount of brownish-red lochia with no odor, which suggests infection resolution and appropriate progression of postpartum uterine involution.
D. Hgb. The client’s hemoglobin dropped from 11.1 g/dL to 10 g/dL, which is below the normal postpartum range. This is likely due to ongoing recovery, recent surgery, and fluid shifts, but it does not indicate improvement and may require continued monitoring.
E. WBC count. The WBC count normalized from a significantly elevated 33,000/mm³ to 10,000/mm³, which is within the normal reference range. This is a strong sign that the infection or inflammatory response is resolving.
F. Fundal height. The fundus has decreased from 1 cm above the umbilicus on day 3 to 4 cm below on day 5, which is consistent with normal involution of the uterus during the postpartum period and is a positive sign of recovery.
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