A nurse is caring for a group of adolescents. Which of the following findings should be reported to the provider immediately?
A client who has a burn injury to an estimated 5% of his leg and is crying
A client who has an ankle fracture reports a pain level increase from 3 to 5 after initial ambulation
A who is a client 1 day postoperative and has a temperature of 37.5° C (99.5° F)
A client's blood pressure changes from 112/60 mm Hg to 90/54 mm Hg when standing
The Correct Answer is D
D. A client's blood pressure changes from 112/60 mm Hg to 90/54 mm Hg when standing.
A significant drop in blood pressure when changing positions from lying to standing may indicate orthostatic hypotension, which can be a sign of dehydration, blood loss, or other underlying medical issues. This can be a cause for concern, especially if the client is an adolescent, as it may lead to decreased perfusion of vital organs and may require immediate medical attention.
The other options are as follows:
A. A client who has a burn injury to an estimated 5% of his leg and is crying - While it's essential to assess and address the client's pain and comfort, this finding does not indicate an immediate need for medical attention. Pain management and wound care can be addressed based on the severity of the burn and the client's pain level.
B. A client who has an ankle fracture reports a pain level increase from 3 to 5 after initial ambulation - This finding is concerning, and the nurse should notify the provider to reassess pain management and evaluate for potential complications related to the fracture. However, it may not require immediate medical attention unless there are signs of severe pain or complications.
C. A client who is 1 day postoperative and has a temperature of 37.5° C (99.5° F) - A slight increase in temperature in the immediate postoperative period may not be unusual and can be attributed to the normal inflammatory response after surgery. The nurse should continue monitoring the client's temperature and report any further changes or additional signs of infection or complications to the provider.
Overall, while all findings should be addressed and managed appropriately, the significant drop in blood pressure (option D) should be reported immediately due to the potential implications for the client's overall health and well-being.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
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.
Correct Answer is B
Explanation
Following a cardiac catheterization, the nurse should provide the parent with appropriate discharge instructions to ensure the child's proper recovery. The correct instruction to include is option B: "Give the child acetaminophen for discomfort."
Explanation:
Option A: Offering the child clear liquids for the first 24 hours is not a typical instruction following a cardiac catheterization. After the procedure, the child may be allowed to resume a regular diet, as tolerated, based on the healthcare provider's orders.
Option B: This is the correct instruction. After cardiac catheterization, the child may experience some discomfort at the insertion site or the area where the catheter was threaded through the blood vessels. Acetaminophen can be used to manage mild pain or discomfort.
Option C: Taking a tub bath for the first 3 days is not typically mentioned in discharge instructions after a cardiac catheterization. The nurse might advise the parent to avoid submerging the catheter insertion site in water for a specific period and instead use sponge baths until permitted by the healthcare provider.
Option D: Keeping the child home for 1 week is not a standard recommendation for a cardiac catheterization. The recovery period after a cardiac catheterization is usually shorter, and the child can often resume normal activities within a day or two, depending on the specific circumstances of the procedure and the child's condition.
The nurse should thoroughly review the specific discharge instructions provided by the healthcare provider and ensure the parent understands the care required at home, including any restrictions on activities or signs of potential complications that require immediate attention.
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