6-year-old child.

Vomited 3 times in the past 24 hr. Irritable behavior for the past 24 hr. The respiratory infection started 3 days ago.

Brudzinski's and Kernig's signs are positive.

Vital Signs.

Respiratory rate 28/min.

Pulse rate 120/min.

BP 108/64 mm Hg. Pain level of 6 on a scale from 0 to 10. Medication Administration Record.

Vancomycin 300 mg IV q 6 hr following blood cultures.

Acetaminophen 240 mg PO q 6 hr PRN fever.

A nurse is planning care for a child during admission to the facility.

Which of the following actions should the nurse take first?

Obtain a prescription for pain medication.

Initiate seizure precautions.

Collect blood cultures.

Transport the child to obtain a CT scan.

Answer and Explanation

The Correct Answer is B

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Correct Answer is A

Explanation

A. Maintain the irrigation solution rate. B. Replace the indwelling urinary catheter. C. Perform the Credé's maneuver. D. Warm the irrigation solution.

Correct Answer is A

Explanation

Choice A rationale:

Maintaining the irrigation solution rate is appropriate in this situation. Pink-tinged urine in the drainage bag indicates the presence of blood, which is expected after a transurethral resection of the prostate. However, if the bleeding becomes excessive, the healthcare provider should be notified. Adjusting the irrigation solution rate might be necessary based on the provider's orders, but abruptly changing the rate without medical direction could lead to complications.

Choice B rationale:

Replacing the indwelling urinary catheter is not necessary solely based on the presence of pink-tinged urine. It is essential to assess the patient's overall condition and the extent of bleeding before considering catheter replacement. Catheter replacement without a valid reason can increase the risk of infection and discomfort for the patient.

Choice C rationale:

Performing the Credé's maneuver involves manual compression of the bladder to assist with urine elimination. This maneuver is not indicated in this situation and could potentially cause harm or disrupt the continuous bladder irrigation. It is essential to follow evidence-based practices and avoid interventions that are not appropriate for the patient's condition.

Choice D rationale:

Warming the irrigation solution is not relevant to the situation described. The presence of pink-tinged urine suggests bleeding, which requires careful monitoring and appropriate medical intervention. Warming the solution does not address the underlying cause of the bleeding and should not be the nurse's primary concern in this scenario.

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Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a client who has histrionic personality disorder.Which of the following manifestations should the nurse expect?

Correct Answer is A

Explanation

A nurse is assessing a client who is receiving continuous bladder irrigation following a transurethral resection of the prostate 4 hr ago.The nurse notes pink-tinged urine in the drainage bag.Which of the following actions should the nurse take?

Correct Answer is A

Explanation

A nurse is preparing to remove an IV catheter from the arm of a client who has phlebitis at a peripheral IV site.Which of the following actions should the nurse plan to take?

A nurse on a medical-surgical unit is planning care for four clients. The nurse should plan to use sterile gloves when performing which of the following procedures?

A nurse is caring for a client who is near the end of life and is on complete bed rest.The client states that he needs to have a bowel movement and the nurse offers a bedpan.The client states, "I've always used the bathroom." Which of the following responses should the nurse make?

A nurse is providing discharge teaching to a client following a total gastrectomy.The nurse should instruct the client about which of the following medications?

A nurse is caring for a client who has a new diagnosis of Chlamydia trachomatis.Which of the following actions should the nurse take?

A nurse in an emergency department is assessing a client who reports ingesting thirty diazepam tablets 20 minutes ago. The client is lethargic and has a respiratory rate of 10/min. After securing the client's airway and initiating an IV, which of the following actions should the nurse take next?

A nurse in an outpatient mental health clinic is assessing an adolescent client.The nurse should expect the adolescent to be in which of the following of Erikson's stages of psychosocial development?

A nurse is planning teaching for a client who has a newly implanted implantable cardioverter-defibrillator.Which of the following information should the nurse include?