A nurse is caring for an infant post-surgery for pyloric ...

[nautica902]

A nurse is caring for an infant post-surgery for pyloric stenosis. Which nursing interventions are appropriate when providing care for this infant?
 
  Select all that apply.
  A) Administer analgesics, per order.
  B) Instruct the parents on proper diapering to avoid pressure over the incision.
  C) Encourage swaddling and rocking to facilitate relaxation.
  D) Teach the parents to remove the steri-strips during the infant's first bath post-surgery.
  E) Monitor temperature once per shift.

Question 2

The nurse is caring for a client with a urinary catheter. Which nursing diagnosis is a priority for this client?
 
  A) Chronic Pain related to an obstruction
  B) Risk for Impaired Skin Integrity related to incontinence
  C) Risk for Infection related to catheter placement
  D) Self-Care Deficit related to presence of urinary catheter

[Kdiggy]

Answer to Question 1

Answer: A, B, C

Nursing interventions for an infant post-surgery for pyloric stenosis include administering analgesics, per order; instructing the parents on proper diapering to avoid pressure on the incision; and encouraging swaddling and rocking to facilitate relaxation. Postoperatively the incision is covered with collodion or Steri-Strips and should be kept clean and dry. The parents should be taught to allow the Steri-Strips to come off on their own. The infant's temperature should be monitored every 4 hours due to the increased risk for infection.

Answer to Question 2

Answer: C

The client who has a urinary catheter in place is at an increased risk for infection, which is the priority diagnosis. There is no indication that the client is experiencing chronic pain. While there is an increased risk for impaired skin integrity and a self-care deficit, these are not priorities for this client.