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. Monitoring the temperature for fever is appropriate as part of a general assessment and could help identify signs of infection.
B. Monitoring blood pressure is important because hypertension can be associated with Wilms tumor.
C. Assessing the urine for hematuria is appropriate, as hematuria can be a symptom of Wilms tumor.
D. Palpating the abdomen is contraindicated in suspected Wilms tumor cases because it could cause the tumor to rupture, potentially spreading cancerous cells. Therefore, palpating the abdomen should be avoided until further diagnostic procedures are performed.
Correct Answer is B
Explanation
Rationale:
A. A child recovering from nasopharyngitis could still be contagious, and since children with leukemia have compromised immune systems, they are at higher risk of infections.
B. A child with nephrotic syndrome, although potentially needing special care, does not pose the same infection risk as a child recovering from an infectious disease. Therefore, they are a more suitable roommate for a child with leukemia.
C. A child with gastroenteritis may still be infectious and could expose the child with leukemia to gastrointestinal pathogens.
D. A child with rheumatic fever does not have a contagious illness, but the specific needs of the child with leukemia and the potential for complications from infections make it less ideal compared to a non-infectious condition like nephrotic syndrome.