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. Granola often contains gluten, so this meal would not be suitable for someone with celiac disease.
B. Cheese, banana slices, rice cakes, and whole milk are gluten-free and appropriate for a child with celiac disease.
C. Rye toast contains gluten, which is contraindicated for someone with celiac disease.
D. Flour tortillas generally contain gluten, so this meal is not appropriate for someone with celiac disease.
Correct Answer is A
Explanation
Rationale:
A. Acetaminophen can be used to manage mild discomfort after cardiac catheterization. It is a safe option for pain relief and is commonly recommended for children following the procedure.
B. Bed rest is typically recommended for a shorter duration, often 24 hours, not a full week. Extended bed rest is not usually required unless complications occur.
C. The diet should be advanced as tolerated, but there is no specific requirement to wait 24 hours; this will depend on the child’s recovery and tolerance.
D. Bathing recommendations often include avoiding submerging the site in water, so a tub bath may not be advised for the first few days to prevent infection. Sponge baths might be recommended instead.