A nurse on a pediatric unit is admitting a 5-year-old child who has a submersion injury and is awake and alert. The parent asks the nurse why the child needs to stay in the facility. Which of the following responses should the nurse make?
"Your child needs mechanical ventilation."
"We need to observe your child for cerebral swelling."
"Your child needs to have an electroencephalogram."
"We need to perform an echocardiogram on your child."
The Correct Answer is B
A. "Your child needs mechanical ventilation." Mechanical ventilation is unnecessary if the child is awake and alert.
B. "We need to observe your child for cerebral swelling." Submersion injuries can lead to complications like cerebral edema or acute respiratory distress syndrome (ARDS), even if the child initially appears stable. Observation is essential to identify and address delayed complications.
C. "Your child needs to have an electroencephalogram." Electroencephalograms (EEGs) are not routine unless seizures or brain activity concerns are present.
D. "We need to perform an echocardiogram on your child." Echocardiograms are not standard for submersion injuries unless cardiac dysfunction is suspected.
Nursing Test Bank
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Related Questions
Correct Answer is D
Explanation
A. Administer IV antibiotics: While urgent, antibiotics can be administered after precautions are in place to ensure safety.
B. Monitor vital signs: Important but not the first action. Vital signs can be monitored after precautions are initiated.
C. Encourage oral fluids: Incorrect because IV fluids are usually required due to the severity of the illness and risk of shock.
D. Initiate droplet precautions. Protecting others from transmission is the highest priority in managing bacterial meningitis, a highly contagious condition.
Correct Answer is A
Explanation
A. Monitor temporal artery temperature: Regularly checking the temporal artery temperature can help identify a fever early, allowing for prompt intervention if necessary.
B. Restrain the infant's wrists: Soft elbow restraints (not wrist restraints) are commonly used for infants post-cleft lip repair to prevent them from touching or rubbing the surgical site, which could disrupt the sutures and delay healing.
C. Place the infant in a prone position: After cleft lip surgery, infants should be positioned on their back to avoid pressure on the sutures and reduce the risk of injury.
D. Gently clean the suture line with povidone-iodine solution: It is typically recommended to clean the suture line with a sterile saline solution rather than povidone-iodine, which may irritate the site. Additionally, care should be taken to avoid disturbing the area too much.
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