A nurse is working with an assistive personnel (AP) to care for a group of clients on the pediatric unit. Which of the following tasks should the nurse have the AP perform first?
Check to see if the elbow restraint is in place for an infant who is postoperative from a surgical correction of a cleft palate.
Wash the hair of an adolescent who reports extreme fatigue and is scheduled for radiation therapy for the treatment of Hodgkin lymphoma.
Collect a stool sample for ova and parasites from a school-age child
Engage a toddler in play.
The Correct Answer is A
Rationale:
A. Check to see if the elbow restraint is in place for an infant who is postoperative from a surgical correction of a cleft palate is a priority to ensure the safety and proper positioning of a vulnerable postoperative patient.
B. Wash the hair of an adolescent who reports extreme fatigue and is scheduled for radiation therapy for the treatment of Hodgkin lymphoma can be done later, as it is not as critical as ensuring the safety of a postoperative infant.
C. Collect a stool sample for ova and parasites from a school-age child is important but not as urgent as checking restraints for a postoperative infant.
D. Engage a toddler in play is important for developmental support but is not as urgent as tasks directly related to patient safety and postoperative care.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","E"]
Explanation
A. While the client's temperature is not extremely high, it is elevated and persistent. Requesting an antipyretic or further evaluation may be warranted to prevent potential complications.
B. Insertion of NG tube for decompression is not necessary as the client is passing flatus and has bowel sounds in all quadrants, indicating normal gastrointestinal function.
C. Oxygen 2 to 4 L/min via nasal cannula is not necessary since the client's SpO2 levels are within normal range on room air.
D. The client's urinary output is adequate (400 mL over 6 hours), so a catheter is not required at this time.
E. The lack of drainage from the wound drain could indicate a problem that requires immediate attention. This could prevent complications like infection or fluid accumulation.
Correct Answer is ["B","D","E","F","H","I"]
Explanation
Rationale:
A. Typically involved in helping clients with activities of daily living due to physical or cognitive impairments, which is not the primary focus in this scenario.
B. May be involved if there is a need for possible surgical management due to complications or disease progression. Surgical intervention can be necessary for Crohn's disease, particularly if there are abscesses, strictures, or fistulas.
C. While important in general rehabilitation, physical therapy is not specifically indicated in this case unless there are complications affecting physical mobility.
D. The provider ordered Magnetic Resonance Enterography (MRE) to evaluate the small intestines and pelvis. A radiologist will interpret imaging studies to assess disease severity, fistulas, strictures, or abscesses.
E. Essential for managing nutritional needs, especially given the client's weight loss and inability to keep food down. A dietitian can help develop a plan to address nutritional deficiencies and manage symptoms through diet.
F. A specialist in gastrointestinal diseases who will likely be a key member of the team for managing and evaluating the client's Crohn's disease, overseeing medical and therapeutic interventions.
G. Generally involved if there are issues with swallowing or speech, which is not indicated here.
H. The client is on corticosteroids and may need immunosuppressive therapy, which requires medication management. A pharmacist ensures the correct dosage, drug interactions, and education on potential side effects.
I. Important for addressing psychosocial issues, such as the client's frustration and possible depression. They can assist with coping strategies, support services, and facilitating access to community resources.
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