A pediatric nurse is caring for multiple clients and reviewing each of their care plans. Which of the following client care interventions requires revising?
Administer a bronchodilator two times a day for a child who has cystic fibrosis.
Check the neurovascular status every 4 hr of a child who had a hip spica cast placed 6 hr ago
Maintain eye shields for a newborn receiving phototherapy for hyperbilirubinemia.
Teach an adolescent who has an exacerbation of ulcerative colitis about a high-protein, low-fiber diet
The Correct Answer is D
Choice A reason: Administering a bronchodilator two times a day for a child who has cystic fibrosis is an appropriate intervention, as it helps to improve the child's respiratory function and prevent mucus accumulation.
Choice B reason: Checking the neurovascular status every 4 hr of a child who had a hip spica cast placed 6 hr ago is an appropriate intervention, as it helps to monitor the child's circulation and nerve function and detect any signs of compartment syndrome.
Choice C reason: Maintaining eye shields for a newborn receiving phototherapy for hyperbilirubinemia is an appropriate intervention, as it helps to protect the newborn's eyes from the harmful effects of the light and prevent eye damage.
Choice D reason: Teaching an adolescent who has an exacerbation of ulcerative colitis about a high-protein, low-fiber diet is an incorrect intervention, as it contradicts the dietary recommendations for this condition. A high-protein, low-fiber diet can worsen the inflammation and symptoms of ulcerative colitis. The nurse should teach the adolescent about a low-residue, high-calorie, high-protein diet instead.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A reason: An aPTT (activated partial thromboplastin time) of 34 seconds is within the therapeutic range for heparin therapy. There is no immediate need for an interdisciplinary conference based solely on this result. The nurse can continue monitoring the client's aPTT and adjust heparin dosing as needed. The aPTT value is appropriate for the client's condition, and no urgent intervention is required.
Choice B reason: Insulin pump management primarily involves coordination between the patient and the diabetes care team. While education and ongoing support are essential, an interdisciplinary conference is not typically necessary for routine insulin pump use. Insulin pump management is a well-established process that does not require immediate collaboration among multiple disciplines.
Choice C reason: Orthostatic hypotension is a condition where blood pressure drops significantly upon standing. IV fluids are commonly used to manage orthostatic hypotension by increasing blood volume and improving blood pressure regulation. An interdisciplinary conference would involve collaboration among healthcare professionals to address the client's specific needs related to orthostatic hypotension, fluid management, and prevention of complications. Orthostatic hypotension requires coordinated efforts from various disciplines to optimize care.
Choice D reason: While albumin levels are relevant for assessing nutritional status and wound healing, this specific scenario does not necessitate an interdisciplinary conference. Pressure ulcer prevention and management can be addressed through routine nursing assessments and interventions. Pressure ulcer risk and albumin levels can be managed within the nursing scope without immediate interdisciplinary collaboration.
Correct Answer is B
Explanation
Choice A reason: Placing a surgical mask on the client during transfer to the unit is not an appropriate action for the nurse to take. Cutaneous anthrax is not transmitted through respiratory droplets, but through direct contact with the spores that enter the skin. A surgical mask does not protect the client or others from the infection.
Choice B reason: Preparing to administer antibiotics to the client is an appropriate action for the nurse to take. Cutaneous anthrax is caused by a bacterium called Bacillus anthracis, which can be treated with antibiotics, such as ciprofloxacin or doxycycline. Antibiotics can prevent the infection from spreading to other parts of the body and causing serious complications.
Choice C reason: Planning to administer an antiviral medication to the client is not an appropriate action for the nurse to take. Cutaneous anthrax is not caused by a virus, but by a bacterium. Antiviral medications are ineffective against bacterial infections and may cause adverse effects or interactions.
Choice D reason: Wearing an N95 respirator mask while caring for the client is not an appropriate action for the nurse to take. An N95 respirator mask is used to protect the nurse from airborne pathogens, such as tuberculosis or measles. Cutaneous anthrax is not airborne, but contact-based. The nurse should wear standard precautions, such as gloves and gown, and wash their hands thoroughly after caring for the client.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.