A nurse is caring for a school-age child who was involved in a motor vehicle crash.
Complete the following sentence by using the list of options.
The child is at highest risk for developing
The Correct Answer is {"dropdown-group-1":"B","dropdown-group-2":"D"}
Hypoxia (Low Oxygen Levels): The child's oxygen saturation has decreased from 95% to 93% on room air, which indicates a decline in oxygenation. Although this level is still within an acceptable range, a further drop could indicate respiratory compromise, especially with signs of labored breathing and a nonproductive cough.
Rationale for incorrect options:
Hypotension: The child's blood pressure remains stable (110/64 mm Hg), ruling out a significant risk of hypotension.
Constipation: While the child has hypoactive bowel sounds and hasn't had a bowel movement in two days, this does not pose the most immediate risk.
Dehydration: The child voided 200 mL of clear, yellow urine, suggesting adequate hydration status.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
A. Change the formula to a nonmilk option to decrease colic symptoms. – Incorrect. Formula changes are not always necessary unless the infant has a suspected milk allergy.
B. Avoid holding or cuddling my baby to prevent colic symptoms. – Incorrect. Comforting measures like rocking can actually help soothe a colicky baby.
C. Give my baby a warm bath before bedtime to soothe colic symptoms. – Incorrect. While a warm bath may be comforting, burping is a more direct way to reduce gas buildup.
D. Burp my baby often during feedings to reduce gas. – Correct. Frequent burping helps prevent air accumulation, which can contribute to colic.
Correct Answer is ["A","B","D","E"]
Explanation
A. Provide frequent and routine verbal updates with the parents. – Correct. Keeping parents informed can help alleviate anxiety.
B. Encourage the parents to participate in the toddler's plan of care when appropriate. – Correct. Involvement can help them feel more in control and engaged.
C. Perform more frequent health care rounds on the toddler. – Incorrect. While rounding is beneficial, it does not directly address parental distress.
D. Conduct interprofessional rounds at the child's bedside so the parents can be included. – Correct. This allows parents to hear updates directly from the care team.
E. Provide education to the parents on all nursing interventions to alleviate added anxiety about tasks they are unfamiliar with. – Correct. Education helps parents feel more comfortable with their child's care.
F. Provide the parents with the nurse's personal cell phone number to contact if they have questions while they are away from the hospital. – Incorrect. Professional communication should go through appropriate hospital channels.
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