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 B
Explanation
Rationale:
A. Regular testing of urine for glucose is not specific to nephrotic syndrome and is more relevant for managing diabetes.
B. Weighing the child on the same scale each day is essential for monitoring fluid status and detecting early signs of fluid retention or loss, which are critical in managing nephrotic syndrome.
C. Increasing oral fluid intake may not be recommended due to the risk of fluid retention and edema, which are common in nephrotic syndrome.
D. While monitoring potassium levels is necessary when on diuretics like furosemide, a low-potassium diet is not routinely required unless hyperkalemia is present.
Correct Answer is D
Explanation
Rationale:
A. While monitoring blood pressure is important, a blood pressure of 98/62 mm Hg may not immediately warrant notification unless there are signs of hypotension or other symptoms. The focus should be on careful management of fluid and electrolytes.
B. In cases of acute renal failure, potassium levels can become elevated due to impaired renal function. Therefore, IV fluids should typically be low in potassium to prevent hyperkalemia.
C. In acute renal failure, a diet high in protein and sodium is not recommended. Instead, dietary restrictions are usually advised to manage waste products and fluid balance.
D. Administering IV fluids slowly helps to prevent fluid overload, which is crucial in managing renal failure and maintaining hemodynamic stability.