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A nurse is assisting with planning care for a school-age child on the pediatric unit.

Exhibits

Complete the following sentence by using the lists of options.

The nurse should recommend to

followed by.
Answer and Explanation

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.


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Related Questions

Correct Answer is C

Explanation

A. "It measures the amount of oxygen circulating in the blood." The HbA1c test does not measure oxygen levels. Oxygen levels in the blood are measured through tests like pulse oximetry or arterial blood gas tests.
B. "It measures the amount of immature white blood cells." The HbA1c test measures the average blood glucose levels over the past 2-3 months, not white blood cells. The immature white blood cell count is assessed through a different blood test (e.g., a complete blood count).
C. "It measures the glucose circulating in the blood stream." The HbA1c test reflects the average blood glucose levels over the past 2-3 months by measuring the percentage of hemoglobin that has glucose attached to it.
D. "It measures the amount of red blood cells." The HbA1c test does not measure the number of red blood cells; it measures the percentage of hemoglobin in red blood cells that is bound to glucose, which helps assess blood sugar control over time.

Correct Answer is C

Explanation

A. Show the child's parent how to release tension on the bars: The tension on the halo vest is adjusted by the healthcare provider, not by the parent. The nurse should not instruct the parent to release tension, as improper adjustments can lead to complications.

B. Remove the vest for the child to sleep at night: The halo vest should remain in place at all times, including during sleep, to maintain proper cervical traction and stabilization. Removing it may interfere with the healing process and cause further injury.

C. Check the child's pupillary response: Monitoring the pupillary response is important in a child with cervical traction to assess for any neurological changes. It helps identify signs of increased intracranial pressure or other neurological complications.

D. Apply a cervical collar if the child reports neck pain: The halo vest itself is designed to stabilize the neck, and the application of a cervical collar without provider guidance could interfere with the proper use of the traction system.

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