A nurse is caring for a 9-year-old child on the pediatric unit.
Complete the following sentence by using the lists of options.
The nurse should plan to
The Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"B"}
Rationale for correct choices
• Inspect the child's oropharynx: Vomiting bright red emesis after tonsillectomy indicates possible postoperative hemorrhage. Immediate inspection of the oropharynx allows the nurse to assess the source, amount, and severity of bleeding. Prompt identification of bleeding is critical to prevent hypovolemic shock and guide urgent interventions.
• Obtaining a set of vital signs: Vital signs provide objective data about the child’s hemodynamic status. Tachycardia, hypotension, or altered respiratory rate may indicate significant blood loss. Monitoring blood pressure, heart rate, and oxygen saturation helps determine the urgency of treatment and guides fluid resuscitation or other emergency measures.
Rationale for incorrect choices
• Place the child in a supine position: Placing the child supine could worsen bleeding or increase the risk of aspiration if emesis occurs. Standard care is to maintain the child upright or sitting forward to allow drainage and minimize airway compromise. Supine positioning is not appropriate immediately after post-tonsillectomy bleeding.
• Offer the child a red popsicle: Red-colored foods or drinks can mask the presence of ongoing bleeding, delaying recognition of hemorrhage. It is unsafe to offer red popsicles until bleeding is ruled out and the child is stable. Non-red liquids or clear fluids are safer during assessment.
• Encouraging the child to cough and deep breathe: While coughing and deep breathing are important for postoperative respiratory care, they are contraindicated if active bleeding is suspected. Coughing could dislodge clots and exacerbate hemorrhage. Airway safety and hemodynamic assessment take priority.
• Requesting a prescription for codeine: Administering codeine for pain is inappropriate in the presence of suspected bleeding because opioids can mask symptoms and depress respirations. Pain management should be secondary to stabilization and assessment of hemorrhage risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Rationale:
A. Place the client in supine position: The supine position is not ideal for paracentesis. The procedure is typically performed with the client sitting upright on the edge of the bed or in a high Fowler’s position, allowing fluid to collect in the lower abdomen and reducing the risk of organ puncture.
B. Ensure the client has a full bladder: A full bladder increases the risk of bladder puncture during paracentesis. Clients are usually asked to void before the procedure to minimize this risk and promote safety.
C. Obtain a creatinine level: While kidney function may be relevant to overall health, measuring creatinine is not required specifically for paracentesis. The procedure focuses on removing ascitic fluid and assessing for infection or other complications, not directly on renal function.
D. Weigh the client: Weighing the client before the procedure establishes a baseline to evaluate the amount of fluid removed and monitor changes in fluid status. Pre- and post-procedure weights help assess effectiveness and detect complications such as hypotension or fluid shifts.
Correct Answer is B
Explanation
Rationale:
A. Dietary intake: The client ate 75% of breakfast, which indicates adequate oral intake. While monitoring nutrition is important in schizophrenia, this finding does not pose an immediate safety concern or require urgent reporting.
B. Sore throat: A sore throat in a client taking clozapine is significant because clozapine can cause agranulocytosis, a potentially life-threatening reduction in white blood cells. Any signs of infection, such as sore throat or fever, must be reported immediately to prevent serious complications.
C. Heart rate: A heart rate of 98/min is slightly elevated but within acceptable limits for many adults. This finding alone does not indicate an urgent issue requiring immediate provider notification.
D. Blood pressure: A blood pressure of 102/56 mm Hg is slightly low but may be within the client’s normal range, particularly if the client experiences dizziness when changing positions. While it should be monitored, it does not require urgent reporting unless symptoms worsen.
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