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 B
Explanation
During a sickle cell crisis, the child experiences severe pain due to the sickled red blood cells blocking blood flow in the vessels, leading to tissue ischemia and infarction. Pain is the hallmark symptom of sickle cell crisis and can occur in various parts of the body, such as the abdomen, chest, back, joints, and extremities.
A. Constipation is not a common symptom of sickle cell crisis. It may be associated with other conditions but is not directly related to sickle cell crisis.
C. High fever is not a typical finding in sickle cell crisis. Fever may occur due to infections, which individuals with sickle cell disease are at increased risk of developing, but it is not a direct symptom of the crisis itself.
D. Bradycardia (slow heart rate) is not commonly associated with sickle cell crisis. Tachycardia (rapid heart rate) may occur in response to pain, but bradycardia is not a typical finding.
Correct Answer is A
Explanation
A. Apex of the heart:The apex of the heart is the preferred site for measuring an infant's heart rate. It is located at the 4th or 5th intercostal space, just medial to the midclavicular line, allowing for accurate auscultation of the heartbeat.
B. Carotid artery:While the carotid artery can be used to assess heart rate in older children and adults, it is not ideal for infants due to the risk of compromising circulation to the brain if pressure is applied too forcefully.
C. Brachial artery:The brachial artery is often used to assess pulse in infants, especially in cases of CPR, but it is not the preferred site for routine heart rate measurement. It may be used when assessing circulation or checking for pulses, but auscultation at the apex is more accurate for heart rate.
D. Radial artery:The radial artery can be difficult to palpate in infants due to their small size and is generally not used for heart rate assessment in this age group. The apex is a more reliable location.
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