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. While pain management is important, the primary treatment for pyloric stenosis is surgical correction, not just analgesic medication.
B. Preparation for surgical correction, specifically a pyloromyotomy, is the standard treatment for pyloric stenosis to relieve the obstruction.
C. A barium enema is not used in the diagnosis or treatment of pyloric stenosis; it is typically used to diagnose other gastrointestinal conditions.
D. Thickened feedings with rice cereal are not indicated for pyloric stenosis and would not resolve the obstruction.
Correct Answer is A
Explanation
Rationale:
A. If NSAIDs (nonsteroidal anti-inflammatory drugs) are ineffective in managing symptoms of JIA, the healthcare provider needs to be notified as other treatments, such as disease-modifying antirheumatic drugs (DMARDs) or biologics, may be necessary.
B. Warm compresses, rather than cool compresses, are typically recommended to relieve joint pain and stiffness in JIA.
C. While rest is important, excessive napping can lead to stiffness and decreased mobility. Regular, gentle activity is encouraged to maintain joint function.
D. High-impact exercises like running may be too strenuous for children with JIA and can exacerbate joint pain. Low-impact activities such as swimming or cycling are generally recommended to promote range of motion without putting undue stress on the joints.