The nurse is caring for a 13-year-old who is 2 days post-operative from a laparoscopic appendectomy. Upon assessment, the nurse notes the following vital signs: 37,1°C (98.8°F), a pain rating of 3 out of 10, and breath sounds are diminished in the lower lobes. What action should the nurse take first?
Maintain prone positioning.
Request a laboratory prescription for a white blood cell count.
Administer prescribed acetaminophen.
Encourage the use of an incentive spirometer.
The Correct Answer is D
A. Prone positioning is not recommended post-operatively for abdominal surgery and could exacerbate respiratory issues.
B. While monitoring white blood cell count is important, encouraging lung expansion and preventing complications such as atelectasis is a more immediate priority.
C. The client's pain rating is low and does not necessitate immediate administration of acetaminophen.
D. Encouraging the use of an incentive spirometer helps improve lung expansion, which is crucial to prevent atelectasis and promote proper oxygenation, particularly when breath sounds are diminished.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Tea-colored urine is more typical of glomerulonephritis rather than nephrotic syndrome.
B. A recent streptococcus infection is commonly associated with post-streptococcal glomerulonephritis, not nephrotic syndrome.
C. Polyuria is not a common feature of nephrotic syndrome; rather, oliguria (decreased urine output) may occur.
D. Periorbital edema is a hallmark sign of nephrotic syndrome, resulting from significant protein loss in the urine, leading to hypoalbuminemia and fluid retention.
Correct Answer is A
Explanation
A. Profound cyanosis is a key sign of tricuspid atresia, a congenital heart defect where the tricuspid valve is absent, leading to poor oxygenation of the blood.
B. Periorbital edema is not typically associated with tricuspid atresia; it might be seen in other conditions like nephrotic syndrome.
C. Absent femoral pulses suggest coarctation of the aorta rather than tricuspid atresia.
D. Decreased blood pressure in the lower extremities is also more indicative of coarctation of the aorta, not tricuspid atresia.
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