A nurse is creating a plan of care for a toddler who is recovering following a routine surgical procedure. Which of the following interventions should the include.
Place cooling blanket on the toddler.
Administer IV dantrolene sodium to the toddler.
encourage the toddler to use an incentive spirometer.
Administer aspirin to the toddler as needed for pain.
The Correct Answer is C
The correct answer is Choice C.
Choice A rationale: A cooling blanket is typically used to manage hyperthermia in conditions like malignant hyperthermia, not routine postoperative recovery. It might cause the toddler to become too cold, leading to hypothermia or discomfort.
Choice B rationale: IV dantrolene sodium is administered for malignant hyperthermia, a rare but serious reaction to certain anesthesia medications. It is not appropriate for routine surgical recovery unless such a reaction is suspected or diagnosed.
Choice C rationale: Using an incentive spirometer encourages deep breathing, helping to prevent postoperative respiratory complications like atelectasis and pneumonia. It is an effective tool to promote lung expansion and improve oxygenation in the recovering toddler.
Choice D rationale: Administering aspirin to a toddler is not recommended due to the risk of Reye's syndrome, a serious condition causing swelling in the liver and brain. Alternative pain management strategies should be utilized for pediatric patients.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
Encouraging flexion and extension of the neck in a client with a halo vest for cervical vertebral fracture is not recommended. The purpose of the halo vest is to immobilize the neck to allow healing.
Choice B rationale
Assessing the pin sites for infection once every other day is not typically recommended. More frequent assessments are usually necessary to promptly identify any signs of infection.
Choice C rationale
Repositioning the client using a turning sheet is the correct action. This method of repositioning can help to prevent skin breakdown and pressure ulcers, which are potential complications for clients who are immobilized.
Choice D rationale
Tightening the screw on the halo device once-quarter turn every 48 hours is not typically recommended. Adjustments to the halo device should be made by a healthcare professional as needed based on the client’s condition and comfort.
Correct Answer is ["D"]
Explanation
The correct answer is choiced. Encourage the adolescent to perform incentive spirometry to maintain lung capacity.
Choice A rationale: Avoiding influenza and pneumococcal vaccines for 24 months is not recommended. Vaccinations are crucial for preventing respiratory infections, which can be particularly dangerous for individuals with muscular dystrophy due to their compromised respiratory function.
Choice B rationale: Initiating a referral for chest physiotherapy every 4 hours is excessive and impractical. While chest physiotherapy can be beneficial, it is typically recommended at a frequency that is manageable and tailored to the individual’s needs.
Choice C rationale: Recommending the adolescent use a wheelchair to prevent stress on the lower extremities is not ideal. Encouraging mobility and physical activity as tolerated is important to maintain muscle strength and function for as long as possible.
Choice D rationale: Encouraging the adolescent to perform incentive spirometry to maintain lung capacity is appropriate. Incentive spirometry helps improve lung function and prevent respiratory complications, which are common in individuals with muscular dystrophy.
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