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.

Answer and Explanation

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

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Naxlex Comprehensive Predictor Exams

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Correct Answer is B

Explanation

A. Polyuria is not commonly associated with heart failure in infants; they are more likely to have oliguria or reduced urine output.

B. Difficulty feeding is a common sign of heart failure in infants because the increased work of breathing and poor cardiac output make it hard for them to feed effectively.

C. Bradycardia is not typically associated with heart failure; tachycardia is more common as the heart tries to compensate for decreased cardiac output.

D. Bradypnea is uncommon in heart failure; tachypnea is a more likely symptom due to fluid overload and poor oxygenation.

A. Complete blood count B. Lead screening C. Pregnancy test D. Tuberculosis screening

Correct Answer is C

Explanation

A. A complete blood count is not specifically required before administering the rubella vaccine.

B. Lead screening is not related to rubella vaccination and is not required for this purpose.

C. The rubella vaccine is a live attenuated vaccine, and it is important to ensure that the patient is not pregnant because the vaccine could potentially harm the fetus. Therefore, a pregnancy test is a necessary precaution.

D. Tuberculosis screening is not related to the rubella vaccination and is not required for this purpose.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An infant is admitted to the pediatric unit with heart failure due to a congenital heart defect. What assessment finding would the nurse expect with this diagnosis?

Correct Answer is B

Explanation

A 17-year-old well-female has come to the clinic to get a rubella immunization that is required by the college she plans to attend. Before administering this immunization, the client should have which screening or test?

Correct Answer is C

Explanation

A 3-year-old is diagnosed with spastic cerebral palsy. What information should the nurse include in the discharge teaching?

A nurse is caring for an infant who has diaper dermatitis. What is an appropriate action for the nurse to take when caring for this client?

The nurse is reviewing the medical record of a pediatric client suspected to have acute glomerulonephritis. What finding should the nurse expect to note in a client with this diagnosis?

While assessing a preadolescent client, the nurse notes curvature of the client's spine. Which statement by the parent supports this observation?

The nurse is caring for a 14-year-old client diagnosed with celiac disease. The nurse knows that the client understands the diet instructions when they request which of the following meals?

A nurse has developed a plan of care for a family whose 7-year-old has been experiencing enuresis. Which of the following statements by the parents indicates that further teaching is needed?

The nurse is explaining to parents that the preschooler's developmental task is focused on the development of initiative rather than guilt. What is a priority intervention the nurse might recommend for parents of preschoolers to stimulate initiative?