A nurse is assisting with planning care for a school-age child on the pediatric unit.
div id="exhibits">ExhibitsComplete the following sentence by using the lists of options.
The nurse should recommend to
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Rationale for Correct Choices:
- Check the child's oropharynx: The child has had a tonsillectomy and is showing signs of possible bleeding, indicated by the small amount of bleeding in the posterior pharynx and bright red emesis (vomiting of blood). The nurse should check the oropharynx to assess the amount and source of the bleeding, as this could indicate a complication post-surgery.
- Obtaining a set of vital signs: After vomiting bright red emesis, it is crucial to assess the child's vital signs to monitor for signs of bleeding or shock. Changes in vital signs, especially increased heart rate or decreased blood pressure, could indicate significant blood loss.
Rationale for Incorrect Choices:
- Offer the child a red popsicle: Red-colored foods are generally avoided post-tonsillectomy as they can obscure or be mistaken for blood. More importantly, offering anything by mouth is contraindicated during active bleeding due to the risk of aspiration and potentially dislodging clots.
- Place the child in a supine position: The child should be positioned in a way that allows for the drainage of blood and secretions, ideally with the head elevated. Placing the child in a supine position could cause blood to pool in the throat, increasing the risk of aspiration.
- Encouraging the child to cough and deep breathe: Encouraging coughing and deep breathing immediately after tonsillectomy is not recommended, as it could dislodge a clot or exacerbate bleeding.
- Requesting a prescription for codeine: Although the child is experiencing some pain (rated 3/10), the primary concern at this point is bleeding, not pain. Pain management should be adjusted but the focus should be on addressing the bleeding first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Induce fatigue with vigorous activities close to bedtime: Engaging in vigorous activities close to bedtime can overstimulate the toddler, making it harder for them to wind down and fall asleep. It’s best to avoid stimulating activities in the hour or so before bedtime.
B. Provide the toddler with a light snack before bedtime: A light snack before bedtime can be helpful, as it may prevent hunger from interfering with sleep. The snack should be something that won't cause discomfort or disrupt digestion, like a small piece of fruit or crackers.
C. Allow the toddler to choose their bedtime: While some level of flexibility can be beneficial, allowing a toddler to choose their bedtime may lead to inconsistency and difficulty establishing a healthy sleep routine. A set bedtime helps toddlers establish good sleep habits.
D. Permit the toddler to watch television in bed to promote sleep: Watching television in bed can be overstimulating and interfere with the toddler’s ability to fall asleep. It’s best to have a calm, quiet environment before bedtime to help the child relax and prepare for sleep.
Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"B"}
Explanation
Rationale for Correct Choices:
- Fontanel finding: The sunken fontanel indicates signs of dehydration, which is the primary concern for this infant. Dehydration can lead to severe complications and should be addressed first through appropriate fluid resuscitation (IV fluids) to prevent further deterioration.
- Temperature: The infant has a fever of 38.4°C (101.1°F), which needs to be managed with acetaminophen as prescribed. While dehydration is the priority, the temperature should also be controlled to prevent worsening of the infant's condition and to make the child more comfortable.
Rationale for Incorrect Choices:
- Diaper area: While the excoriated diaper area is concerning, it is not the most urgent issue compared to dehydration, which can quickly worsen. Dehydration and fever management should be prioritized before addressing skin irritation.
- Stool culture results: The positive stool culture for Shigella is important for determining the infection, but addressing the infant's hydration status and fever is more urgent to stabilize the child. The results will guide further treatment but do not need immediate intervention over dehydration.
- Appetite history: While the infant's poor feeding history is significant, addressing dehydration and fever management should take precedence to stabilize the infant before evaluating feeding patterns in more detail.
- Activity tolerance finding: The infant’s fatigue is likely due to dehydration and fever. Stabilizing hydration and controlling the fever will improve the infant’s activity tolerance, making this secondary to the more urgent issues.