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. A PEFR of 45% of the personal best indicates a moderate asthma exacerbation, but immediate hospitalization is not necessarily required unless there are severe symptoms or other indicators of serious distress.
B. At 45% of the personal best PEFR, the child is experiencing a moderate asthma exacerbation. The recommended action is to use a quick-relief inhaler like albuterol, which is effective in providing immediate relief. Inhaled corticosteroids are part of the long-term management but should not replace the use of a quick-relief inhaler during an exacerbation.
C. Salmeterol is a long-acting beta-agonist used for maintenance therapy and is not typically used for acute exacerbations. Albuterol is preferred in this situation for immediate relief.
D. While monitoring PEFR is important, action should be taken when PEFR falls below 50% of the personal best, and more immediate intervention is needed at 45% of the personal best.
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.