A6-week-old infant with pyloric stenosis is scheduled for a pyloromyotomy, Which pre- operative nursing action has highest priority?

Mark an outline of the "olive-shaped mass in the right epigastric area

Initiate a continuous infusion of IV Fluids per prescription.

Monitor amount of intake and infant's response to feedings.

Instruct parents regarding care of the incisional area.

Answer and Explanation

The Correct Answer is B

A. Marking an outline of the "olive-shaped mass" in the right epigastric area is important for diagnosis, but not a priority pre-operatively.
B. Initiating a continuous infusion of IV fluids is crucial to ensure the infant is properly hydrated before the procedure, as pyloric stenosis can cause severe dehydration.
C. Monitoring the amount of intake and the infant's response to feedings is part of ongoing care, but immediate pre-operative hydration takes precedence.
D. Instructing parents regarding care of the incisional area is necessary post-operatively, not before the surgery.

Nursing Test Bank

Quiz #1: RN Exams Pharmacology Exams Quiz #2: RN Exams Medical-Surgical Exams Quiz #3: RN Exams Fundamentals Exams Quiz #4: RN Exams Maternal-Newborn Exams Quiz #5: RN Exams Anatomy and Physiology Exams Quiz #6: RN Exams Obstetrics and Pediatrics Exams Quiz #7: RN Exams Fluid and Electrolytes Exams Quiz #8: RN Exams Community Health Exams Quiz #9: RN Exams Promoting Health across the lifespan Exams Quiz #10: RN Exams Multidimensional care Exams

Get 100+ Naxlex Exit Exams for $79 Try Naxlex NCLEX-RN (14 Day Free-Trial)

Naxlex Comprehensive Predictor Exams

Quiz #1: Naxlex RN Comprehensive online practice 2019 B with NGN Quiz #2: Naxlex RN Comprehensive Predictor 2023 Quiz #3: Naxlex RN Comprehensive Predictor 2023 Exit Exam A Quiz #4: Naxlex HESI Exit LPN Exam Quiz #5: Naxlex PN Comprehensive Predictor PN 2020 Quiz #6: Naxlex VATI PN Comprehensive Predictor 2020 Quiz #8: Naxlex PN Comprehensive Predictor 2023 - Exam 1 Quiz #10: Naxlex HESI PN Exit exam Quiz #11: Naxlex HESI PN EXIT Exam 2

Free Nursing Study Resources

Correct Answer is D

Explanation

Rationale for A: Encouraging rest might seem beneficial, but it does not address the immediate comfort need of the patient who is experiencing severe epigastric pain. Resting in a supine position may actually exacerbate the pain associated with pancreatitis.
Rationale for B: Raising the head of the bed to a 90-degree angle could potentially increase intra-abdominal pressure, which may worsen the pain for a patient with pancreatitis.
Rationale for C: The reverse Trendelenburg position is not typically indicated for pain relief in pancreatitis. This position might be used to promote gastric emptying or to alleviate respiratory distress, but not specifically for pancreatitis pain.
Rationale for D: Leaning forward can help decrease the pain in pancreatitis by reducing the tension on the peritoneal surfaces. Positioning a bedside table for the client to lean across can provide the necessary support for this position, which aligns with the recommendations for pain relief in pancreatitis.

A. Recommend the use of support stockings to enhance venous return. B. Ensure the client receives frequent small meals containing complete proteins. C. Evaluate patency of the AV graft for resumption of hemodialysis D. Instruct the client to continue to follow the prescribed rigid fluid restriction amounts.

Correct Answer is B

Explanation

A. Support stockings may help with peripheral edema, but they do not address the underlying issue of hypoalbuminemia and its consequences.
B. Adequate protein intake is crucial for increasing serum albumin levels, which can help reduce edema and improve the client's nutritional status. This intervention addresses the root cause of
the client's symptoms.

C. Evaluating the patency of the AV graft is important for long-term planning of hemodialysis access, but it is not the immediate priority given the client's current nutritional status and symptoms.
D. Fluid restriction is important in managing peritoneal dialysis patients, but it does not address the immediate concern of hypoalbuminemia and its effects on the client's health.

View Question and Answer

Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.

Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today

A6-week-old infant with pyloric stenosis is scheduled for a pyloromyotomy, Which pre- operative nursing action has highest priority?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A client with pancreatitis complains of severe epigastric pain, so the nurse administers a prescribed narcotic analgesic. Ten minutes later, the client insists on sitting up and leaning forward. Which intervention should the nurse implement?

Correct Answer is D

Explanation

Correct Answer is B

Explanation

A mother calls the nurse to report that at 0900 she administered an oral dose of digoxin to her 4-month-old infant, but at 0920 the baby vomited the medicine. Which instruction should the nurse provide to this mother?

A preschool-aged child who is being treated for Streptococcal pharyngitis returns to the clinic for signs of scarlet fever. Which assessment finding provides the earliest indication to the nurse that the child is experiencing a reaction to the toxins that are created by the Streptococcus bacteria?

The charge nurse is planning for the shift and has a registered nurse (RN) and a practical nurse (PN) on the team. Which client should the charge nurse assign to the RN?

Which laboratory results should the nurse closely monitor in a client who has end-stage renal disease (ESRD)?

When preparing to administer a prescribed medication to a homeless male at a community psychiatric clinic, the client tells the nurse that he usually takes a different dosage. Which action should the nurse take?

A client with cirrhosis of the liver is admitted with complications related to end stage liver disease. Which intervention(s) should the nurse implement? (Select all that apply.)