A nurse in an emergency department is caring for a school-age child.
The nurse is continuing to care for the child. Which of the following actions should the nurse plan to take? Select all that apply.
Maintain NPO status.
Administer an antipyretic.
Initiate an infusion of IV fluids.
Administer a cleansing enema.
Prepare child and parents for ostomy placement.
Educate child and parents about plan of care.
Administer an analgesic.
Administer antibiotics.
Correct Answer : A,B,C,F,G,H
A. Maintain NPO status. The child is at risk for surgery, and maintaining NPO status reduces the risk of aspiration.
B. Administer an antipyretic. Reducing fever can improve comfort and decrease metabolic demand.
C. Initiate an infusion of IV fluids. IV fluids prevent dehydration, especially since the child has had poor oral intake and diarrhea.
D. Administer a cleansing enema. An enema is contraindicated as it may worsen abdominal inflammation or cause perforation.
E. Prepare child and parents for ostomy placement. While surgery may be needed, an ostomy is not always required for appendicitis.
F. Educate child and parents about plan of care. Providing education helps reduce anxiety and ensures understanding of the interventions.
G. Administer an analgesic. Pain management is essential for comfort and reduces physiologic stress.
H. Administer antibiotics. Antibiotics are started preoperatively to manage infection or prevent complications if perforation is suspected.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. "My child will be awake for this procedure.": Incorrect because the child will be under sedation or anesthesia for safety and to prevent distress.
B. "I can take my child home as soon as the procedure is over.": Incorrect because the child must be monitored post-procedure for complications like airway swelling or sedation effects.
C. "The provider will remove the object during this procedure." A bronchoscopy allows visualization and removal of foreign objects from the airway, which is the purpose of the procedure.
D. "After this procedure, I have to wait 48 hours before I can give my child solid foods.": Incorrect because eating is typically resumed after the child recovers from sedation and demonstrates a safe swallow reflex.
Correct Answer is D
Explanation
A. Instruct the child to gargle using salt water every 4 hr: Gargling can irritate the surgical site and increase the risk of bleeding.
B. Give the child fluids using a straw: Using a straw creates suction, which can dislodge the clot and cause bleeding.
C. Ask the child to take deep breaths and cough every 30 min: Coughing can increase pressure on the surgical site and lead to bleeding.
D. Apply an ice collar to the child's neck. An ice collar reduces swelling, pain, and the risk of bleeding by promoting vasoconstriction.
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