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. "Using this machine increases my risk of overdose.": PCA pumps are designed with safety features, including dose limits and lockout intervals, which reduce the risk of overdose. Understanding this helps the client recognize that PCA is a safe method for self-administered pain control when used correctly.
B. “I can get pain medication any time as long as I press the button”: The client can only receive medication according to the programmed dose and lockout interval. Pressing the button repeatedly will not override the safety mechanism, so this reflects a misunderstanding of how PCA pumps function.
C. "My partner can press my pain medication button for me if I am sleeping": PCA pumps are intended for self-administration only. Allowing someone else to press the button (a practice called “PCA by proxy”) can cause overdose and is unsafe, especially if the client is sleeping or sedated.
D. "I will receive a limited amount of pain medication when I press the button.": PCA pumps deliver a preset dose with a lockout interval to prevent overdose. This statement shows the client understands the safety mechanisms in place, indicating correct comprehension of PCA use.
Correct Answer is {"A":{"answers":"A,B"},"B":{"answers":"B"},"C":{"answers":"A,B"},"D":{"answers":"B"},"E":{"answers":"B"}}
Explanation
Rationale:
• Difficulty walking: Bone injury limits weight-bearing ability and causes alterations in gait. Localized pain and instability can make ambulation difficult. Clients often compensate with limping to avoid pressure on the injured limb. In DVT, A clot in the deep veins causes swelling and discomfort, making ambulation painful. The heaviness and fullness in the limb interfere with normal gait. Clients may develop a limp due to localized tenderness.
• Pain: A fracture typically produces sharp, localized pain that worsens with movement. Tissue disruption and swelling contribute to discomfort. The pain limits limb use and is often immediate after injury. DVT often causes aching or cramping pain in the affected limb, especially with walking. Venous congestion and inflammation contribute to tenderness. Pain increases when the calf is compressed or when standing.
• Limb heaviness: Venous obstruction causes blood pooling, producing a heavy and tight sensation. This finding reflects impaired venous return, especially when swelling is also present. It is common in unilateral DVT. A fracture typically causes sharp, localized pain rather than diffuse heaviness. Heaviness is more strongly associated with venous congestion.
• Fever: Low-grade fever may occur due to inflammatory response around the thrombus. Cytokine release produces systemic symptoms during clot formation. It can accompany swelling, warmth, and redness. A simple fracture does not generally cause systemic fever unless infection develops. Fever is more indicative of inflammatory or infectious conditions.
• Edema: Venous blockage leads to unilateral swelling due to trapped fluid and elevated venous pressure. The affected limb becomes warm, enlarged, and firm. This is a hallmark finding in deep vein thrombosis. While swelling may occur after a fracture, the client’s presentation shows significant unilateral edema matching venous obstruction.
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