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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 {"A":{"answers":"B"},"B":{"answers":"A"},"C":{"answers":"A"},"D":{"answers":"A"},"E":{"answers":"A"},"F":{"answers":"A"}}

Explanation

  • Maintain infant in supine position: Given the infant's respiratory distress, including labored breathing, retractions, and nasal flaring, placing the infant in a supine position could worsen respiratory difficulties. The infant should be kept upright or in a semi-Fowler’s position to promote optimal breathing.
  • Prepare the infant for a chest x-ray: A chest x-ray is crucial to assess the infant’s respiratory status and potential cardiac issues to identify any underlying causes of the symptoms, such as pneumonia, wheezing, cough, and labored breathing.
  • Maintain infant on continuous pulse oximetry: Continuous pulse oximetry is essential for monitoring the infant's oxygen saturation levels. The infant is already on supplemental oxygen, and continuous monitoring will ensure that the oxygen levels are maintained and help identify any worsening of the respiratory condition.
  • Monitor intake and output: Given the infant's poor feeding (consuming only half a bottle in the past 24 hours), monitoring intake and output is crucial to assess hydration status and nutritional needs. Decreased intake and output can indicate dehydration or worsening of the infant's condition.
  • Initiate a peripheral IV line: Due to the infant’s poor feeding and the possibility of dehydration, establishing a peripheral IV line will allow for proper hydration and the administration of fluids or medications, as necessary, for the infant’s condition.
  • Offer small, frequent feedings: Offering small, frequent feedings is appropriate for an infant with respiratory distress and decreased appetite. This can reduce the risk of aspiration and help ensure the infant receives adequate nutrition despite the difficulty with feeding.

Correct Answer is ["A","C","E"]

Explanation

A. Ensure the scale is balanced to "0" before weighing the infant: It is important to calibrate the scale to "0" before weighing the infant to ensure an accurate measurement. This step helps to avoid any errors in weight assessment.
B. Place a stadiometer on the top of the infant's head to measure their length: A stadiometer is typically used for measuring height in older children and adults, but for infants, a length board (not a stadiometer) should be used.
C. Cover the scale with a clean sheet of paper: This is essential for hygiene and to provide a clean, warm surface for the infant, especially when they are undressed for weighing.
D. Obtain the infant's weight with their diaper on: To obtain an accurate weight, the infant should be weighed without the diaper. A diaper adds weight that could affect the accuracy of the measurement.
E. Measure the infant's length from the crown of the head to the heels of the feet: For accurate length measurements in infants, the measurement should be taken from the crown of the head to the heels of the feet while the infant is lying flat on a length board.

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