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.
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Correct Answer is D
Explanation
Rationale:
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 C
Explanation
Rationale:
A. Decreased urine specific gravity is not typical; rather, increased specific gravity may be noted due to concentrated urine.
B. Hypotension is not usually associated with acute glomerulonephritis; hypertension is more common due to fluid retention and renal impairment.
C. A positive antistreptolysin O titer indicates a recent streptococcal infection, which is often the cause of post-streptococcal glomerulonephritis.
D. Elevated blood urea nitrogen (BUN) and creatinine levels are expected due to impaired kidney function, not low levels.