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 C
Explanation
Rationale:
A. A capillary refill greater than 3 seconds suggests ongoing dehydration and poor perfusion, indicating that oral rehydration has not been fully effective.
B. A respiratory rate of 24/min is within normal limits for a 4-year-old but is not a direct indicator of hydration status.
C. A urine specific gravity of 1.015 is within the normal range, indicating adequate hydration and that oral rehydration therapy has been effective.
D. A heart rate of 130 bpm, while potentially normal for a 4-year-old, does not specifically indicate the effectiveness of rehydration therapy.
Correct Answer is D
Explanation
Rationale:
A. Barrier creams should not be washed off with each diaper change; they should be left intact to protect the skin.
B. Cloth diapers can sometimes exacerbate diaper dermatitis due to moisture retention; disposable diapers may be better at wicking moisture away from the skin.
C. Talcum powder is not recommended due to the risk of inhalation, which can cause respiratory issues in infants.
D. Exposing the excoriated area to air frequently allows the skin to dry out, reducing moisture and irritation, which is beneficial in managing diaper dermatitis.