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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 D

Explanation

A. Able to unzip a zipper. This fine motor skill typically develops closer to age 2 to 3 years. At 15 months, most toddlers do not yet have the dexterity required to manipulate clothing fasteners.
B. Builds a tower of 4 cubes. A 15-month-old can usually build a tower of 2 to 3 cubes, while building a tower of 4 or more cubes is more typical around 18 to 24 months.
C. Throws a ball without falling. While some toddlers may attempt to throw a ball, doing so without falling is more characteristic of children around 18 months or older as balance improves.
D. Walks without help. This is an expected milestone by 12 to 15 months. Most toddlers at 15 months are able to walk independently, though gait may still be wide-based and unsteady.

Correct Answer is A

Explanation

A. "The estimated blood loss was 250 milliliters." This is a relevant clinical detail that directly impacts the client’s postoperative care. It provides important information for ongoing assessment of fluid status, potential for anemia, and need for interventions.
B. "The client was intubated without complications." While important during surgery, this is less relevant in the postoperative period unless the intubation caused complications or the client remains intubated. It does not guide current nursing care.
C. "There was a total of 10 sponges used during the procedure." Sponge counts are part of surgical safety and accountability, but they are not typically necessary in nursing hand-off unless a retained item is suspected.
D. "The client is a member of the board of directors." This is not clinically relevant and could breach confidentiality or bias care. Hand-off reports should focus solely on the client’s medical condition and nursing care needs.

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