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
Rationale:
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.
Free Nursing Test Bank
- Free Pharmacology Quiz 1
- Free Medical-Surgical Quiz 2
- Free Fundamentals Quiz 3
- Free Maternal-Newborn Quiz 4
- Free Anatomy and Physiology Quiz 5
- Free Obstetrics and Pediatrics Quiz 6
- Free Fluid and Electrolytes Quiz 7
- Free Community Health Quiz 8
- Free Promoting Health across the Lifespan Quiz 9
- Free Multidimensional Care Quiz 10
View Related questions
Correct Answer is C
Explanation
Rationale:
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.
Correct Answer is C
Explanation
Rationale:
A. Tender inguinal lymph nodes are not associated with celiac disease and are more indicative of localized infections or lymphadenopathy.
B. An enlarged liver is not typically related to celiac disease but may occur in other conditions such as fatty liver disease.
C. A protuberant abdomen is a common finding in children with celiac disease due to malabsorption and gas accumulation in the intestines. This is often accompanied by abdominal distension and discomfort.
D. Periorbital edema is not characteristic of celiac disease and is more commonly seen in conditions like nephrotic syndrome.