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 A
Explanation
Rationale:
A. Topical corticosteroid ointments are commonly used to reduce inflammation and treat flare-ups in children with eczema. The nurse should instruct the parent on the proper use of these medications.
B. Bubble baths can be irritating to the skin and should be avoided, especially in children with eczema, as they can exacerbate dryness and irritation.
C. The skin should be patted dry rather than rubbed, and moisturizers should be applied while the skin is still slightly damp to help retain moisture.
D. Fabric softeners can be irritating to sensitive skin and are not recommended for laundering the clothing of children with eczema.
Correct Answer is B
Explanation
Rationale:
A. Limiting caffeinated beverages is a good strategy as caffeine can increase urine production and contribute to enuresis.
B. Limiting fluid intake during the day is not recommended as it can lead to dehydration. Instead, fluids should be limited in the evening before bedtime.
C. Waking the child at scheduled intervals to void is a common behavioral strategy to help manage enuresis.
D. Anticholinergic medications may be prescribed if behavioral strategies are ineffective, indicating that the parents have received proper education on this potential intervention.