A nurse is caring for a child who is 2 hr postoperative.
Which of the following actions should the nurse take first? (Click the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)
Compare the child's pedal pulses.
Determine the child's sedation level.
Assess the child's pain level.
Recheck the child's temperature.
Correct Answer : A
Given the child's recent motor vehicle accident and subsequent orthopedic surgeries, assessing the peripheral circulation is crucial. Comparing pedal pulses helps to determine the adequacy of blood flow to the lower extremities and identify any potential complications such as compartment syndrome. This assessment should be prioritized immediately.
While assessing pain, sedation level, and rechecking temperature are all important, they do not take precedence over assessing the child's circulation and perfusion status following major orthopedic surgeries.
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Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Crying is a common response to post-operative pain. While it should be addressed, it's not the most critical concern.
B. Adequate hydration is essential, but it's not as critical as the risk of hemorrhage.
C. Pain management is crucial, but it's not the most immediate concern.
D. Frequent swallowing is a classic sign of postoperative hemorrhage. It indicates the child is trying to clear blood from the throat. This is the priority assessment finding and requires immediate intervention.
Correct Answer is D
Explanation
A. Toddlers are typically moving towards independence, not increased dependency. This is a stage of exploration and asserting their autonomy.
B. Toddlers are known for their intense emotions and rapid mood swings. This is a normal part of their development.
C. While toddlers can be unpredictable, they often thrive on routines. However, they also enjoy exploring new things, which can sometimes lead to resistance to established routines.
D. The "terrible twos" is a common phrase for a reason. Toddlers often assert their independence through negative responses, such as saying "no" or throwing tantrums.
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