Which of these assessments is the priority for an infant who is diagnosed with Hirschsprung disease?
Total white blood cell count 7,000/mm.
Serum potassium 4.2 mEq/L.
Nonbilious vomiting.
Watery diarrhea.
The Correct Answer is C
Choice A rationale:
While monitoring the total white blood cell count is important, it is not the priority assessment for a child with Hirschsprung disease. The disease primarily affects the gastrointestinal system.
Choice B rationale:
Serum potassium level within the normal range (4.2 mEq/L) is relevant, but it doesn't take precedence over assessing symptoms directly related to Hirschsprung disease.
Choice C rationale:
Nonbilious vomiting could indicate a bowel obstruction, a potential complication of Hirschsprung disease. Prompt assessment is necessary to prevent further complications.
Choice D rationale:
Watery diarrhea might occur in Hirschsprung disease, but it's not as urgent as addressing vomiting, which could indicate a more immediate problem like bowel obstruction.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Pancreatic enzymes are used to aid in digestion and are not known to interact significantly with serum creatinine levels. Therefore, they are unlikely to be contraindicated based solely on an elevated serum creatinine level.
Choice B rationale:
Gentamicin is an aminoglycoside antibiotic that is primarily eliminated by the kidneys. Elevated serum creatinine levels indicate potential renal impairment, which could lead to reduced drug clearance and an increased risk of gentamicin toxicity, including nephrotoxicity and ototoxicity. Consulting the health care provider before administering gentamicin is important to ensure the appropriateness of the medication dosage and regimen.
Choice C rationale:
Albuterol is a bronchodilator commonly used to treat respiratory conditions. Serum creatinine levels are not directly related to albuterol administration. It is unlikely that an elevated serum creatinine level would significantly affect the administration of albuterol.
Choice D rationale:
Carbenicillin is an antibiotic that is excreted through the kidneys. While renal function may impact the dosing of carbenicillin, an elevated serum creatinine level alone may not necessarily warrant consultation with the health care provider. Other factors such as the severity of renal impairment and the patient's overall condition would need to be considered.
Correct Answer is A
Explanation
Choice A rationale:
Monitoring the apical pulse is of the highest priority for a patient with a myelomeningocele preoperatively. A myelomeningocele is a neural tube defect that can lead to neurologic complications. Monitoring the apical pulse every hour helps detect any signs of cardiac distress or neurological compromise, allowing prompt intervention.
Choice B rationale:
Maintaining the patient in a prone position is not the priority in this situation. While positioning can be important, monitoring vital signs takes precedence over positioning.
Choice C rationale:
Providing sensory stimulation is important for the patient's overall well-being, but it's not the highest priority preoperatively. Monitoring vital signs and assessing for potential complications take precedence.
Choice D rationale:
Keeping a strict record of the patient's intake and output is important for general care, but it's not the highest priority in the immediate preoperative period. Monitoring vital signs and detecting signs of distress come first.
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