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A nurse on a pediatric unit is caring for a preschooler who is postoperative following an appendectomy.

Exhibits

Complete the following sentence by using the lists of options.

The child is at risk for developing

as evidenced by their. and.
Answer and Explanation

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.


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Related Questions

Correct Answer is C

Explanation

A. An angiocatheter. This is used for peripheral IV access, not for accessing implanted venous ports. It is not designed to penetrate the septum of a port safely or effectively.
B. A 25-gauge needle. This needle is too small and not suitable for accessing a venous port, as it may not deliver adequate flow and can damage the port's septum.
C. A noncoring needle. Also known as a Huber needle, this is the correct choice for accessing an implanted port. It has a deflected tip that prevents coring (removing pieces of the port’s septum), preserving the integrity of the port and reducing the risk of damage or infection.
D. A butterfly needle. These are typically used for short-term venous access or blood draws and are not appropriate for accessing an implanted port. They lack the design necessary to protect the septum of the device.

Correct Answer is C

Explanation

A. “Take your diuretic medication with your evening meal." Taking diuretics in the evening can increase nighttime urination, worsening sleep disruption and incontinence. They should generally be taken in the morning to minimize nocturia.
B. "Decrease your intake of cranberry juice." Cranberry juice is often recommended to promote urinary tract health, though it doesn’t directly worsen urge incontinence. It is not necessary to avoid it unless advised by a provider for another reason.
C. "Plan to urinate every 3 hours while you are awake." Scheduled voiding at regular intervals is a key strategy in bladder retraining. It helps reduce urgency episodes and gradually increases bladder capacity and control over time.
D. “Limit your fluid intake to 500 milliliters per day." Severely limiting fluids can lead to dehydration, concentrated urine, and bladder irritation, potentially worsening incontinence. Adequate fluid intake should be maintained unless otherwise directed.

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