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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Free Nursing Study Resources

Correct Answer is B

Explanation

A. Offering a pacifier is contraindicated after cleft lip and palate repair as it can disrupt the surgical site and interfere with healing.

B. Maintaining elbow restraints prevents the infant from touching or putting objects in their mouth, which could disrupt the surgical site and compromise healing.

C. The Trendelenburg position is not recommended as it can increase pressure on the surgical site and compromise breathing.

D. An ice collar may be used for pain relief in older children or adults but is not typically used in infants, and it may not be feasible in this population.

A. Upper gastrointestinal series to determine structural abnormalities from gastroesophageal reflux B. Biopsy of small intestine mucosa to rule out celiac disease C. Ultrasound to assess for presence of pyloric stenosis D. Lower gastrointestinal series to assess for an intestinal blockage

Correct Answer is A

Explanation

A. An upper gastrointestinal series is commonly used to diagnose gastroesophageal reflux (GER), which can cause symptoms like spitting up and crying after feedings, leading to failure to thrive. This test helps visualize the esophagus, stomach, and duodenum for abnormalities.

B. A biopsy of the small intestine is typically done to diagnose celiac disease, which is less likely in this clinical scenario.

C. An ultrasound is used to diagnose pyloric stenosis, which presents with projectile vomiting and is less consistent with the described symptoms.

D. A lower gastrointestinal series is used to detect intestinal blockages, which are not suggested by the symptoms of spitting up and crying immediately after feeding.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an infant in the post-anesthesia care unit following cleft lip and palate repair. What is an appropriate action for the nurse to take?

Correct Answer is B

Explanation

A pediatric client is admitted to the unit with failure to thrive. The mother states that the child has been "spitting up" and excessively crying immediately after every bottle. What diagnostic test will the nurse anticipate to confirm a diagnosis?

Correct Answer is A

Explanation

A first-time parent is pending discharge from the hospital with a well-newborn. What information should the nurse include in the discharge teaching to the parents?

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?

The nurse is caring for a pediatric client admitted with nephrotic syndrome. What assessment finding would likely be noted in a client with this diagnosis?

A 4-year-old client presents to the emergency department with drooling, agitation, and inability to cough. The nurse should recognize these findings are associated with which diagnosis?

A 1-month-old infant is seen in a clinic and is diagnosed with developmental dysplasia of the hip (DDH). On assessment, the nurse understands that which finding would be noted in this condition?

During a well-check for a 12-month-old, the nurse plans to administer the first dose of the varicella vaccine. What is an appropriate action for the nurse to take?

A nurse is caring for a 3-year-old child who has had 160 mL of urine output over the past 8 hour period. The child weighs 33 lb. After calculating the client's urinary output, which action is appropriate?