A nurse is caring for a child who has suspected appendicitis. Which of the following provider prescriptions should the nurse clarify?
Monitor oral temperature every 4 hr.
Administer sodium biphosphate/sodium phosphate.
Maintain NPO status.
Medicate the client for pain every 4 hr as needed.
The Correct Answer is B
The nurse should clarify the prescription to administer sodium biphosphate/sodium phosphate because it is a laxative and is contraindicated in a child with suspected appendicitis. The use of laxatives or enemas can potentially worsen the condition by increasing the risk of perforation or rupture of the inflamed appendix.
A. Monitoring oral temperature every 4 hours is important to assess for signs of infection or worsening condition.
C. Maintaining NPO status is essential to avoid stimulating the digestive system and to prepare for possible surgery.
D. Medicating the client for pain every 4 hours as needed is appropriate to manage pain and provide comfort while the child awaits further evaluation or treatment.
Remember, it's crucial to avoid the use of laxatives, enemas, or any other interventions that can potentially aggravate the inflamed appendix in a child with suspected appendicitis.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
The nurse should expect to find irritability in an infant who is dehydrated. Dehydration in infants can lead to changes in behavior and irritability due to the imbalance in fluid and electrolytes. Other common signs of dehydration in infants may include:
Poor skin turgor (skin tenting)
Sunken fontanelles (soft spots on the baby's head)
Dry mucous membranes (dry mouth and tongue)
Decreased urine output or concentrated urine
Rapid heart rate (tachycardia)
Increased respiratory rate
Sunken eyes
Decreased tears when crying
B. Tetany is a condition characterized by involuntary muscle contractions and is more commonly associated with hypocalcemia (low calcium levels) rather than dehydration.
C. A slow, bounding pulse is not typically associated with dehydration. Dehydration often leads to a rapid heart rate (tachycardia) as the body attempts to compensate for the loss of fluid.
D. Decreased temperature is not a typical finding in dehydration. Dehydration can lead to fever in some cases due to an underlying infection, but it does not cause a decrease in body temperature on its own.
Correct Answer is B
Explanation
Correct answer: B
A. Increased pain: Increased pain is a common and expected finding after a tonsillectomy. The surgical removal of tonsils creates wounds in the throat, which can cause discomfort and pain during the healing process. However, increased pain alone is not a specific manifestation of hemorrhage. Hemorrhage would be indicated by other signs, such as drooling, frequent swallowing, or vomiting blood.
B. Frequent swallowing: This can indicate that the child is swallowing blood, which is a common sign of bleeding at the surgical site. Children might not always show obvious signs of bleeding in the mouth, so frequent swallowing can be a subtle but critical indicator of hemorrhage.
C. Poor fluid intake: Poor fluid intake is a common concern after a tonsillectomy due to postoperative pain and discomfort in the throat. The child may be reluctant to drink or eat initially because of their sore throat. However, poor fluid intake alone is not an indicative sign of hemorrhage. Hemorrhage would present with other symptoms, such as drooling, frequent swallowing, or vomiting blood.
D. Drooling:While drooling can occur due to discomfort, pain, or difficulty swallowing, it is not as specific or immediate a sign of hemorrhage as frequent swallowing.
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