Exhibits
A nurse is caring for a child who is 2 hr postoperative. Which of the following actions should the nurse take first? (Click the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)
Assess the child's pain level.
Recheck the child's temperature.
Determine the child's sedation level.
Compare the child's pedal pulses.
The Correct Answer is D
A. While assessing pain level is important, ensuring adequate perfusion and circulation takes precedence.
B. Rechecking the child's temperature may be necessary but is not as immediately critical as assessing pedal pulses.
C. Determining the child's sedation level is important for monitoring postoperative status but is not the priority at this time.
D. Assessing the child's pedal pulses is crucial following a motor-vehicle crash and surgical procedures involving the lower extremities. It helps to evaluate the perfusion and circulation to the extremities, especially after a leg open reduction and fixation surgery.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
A. Preparing for a change in all routines may cause unnecessary anxiety for the child. Changes should be introduced gradually and as needed.
B. Providing a doll allows the child to imitate parental behaviors, fostering a sense of involvement and understanding.
C. Simply informing the child about a new playmate may not adequately prepare them for the arrival of a sibling.
D. Waiting for the newborn to come home before transitioning the older child from a crib to a bed may not be necessary and could delay the transition unnecessarily.
Correct Answer is D
Explanation
A. Requesting assistance from the anesthesiologist may not be appropriate as they may not be as familiar with the specifics of the procedure as the provider performing it.
B. Explaining the procedure is not the nurse's role.
C. Witnessing the signature is a procedural task that does not address the guardian's need for understanding the necessity of the procedure.
D. Notifying the provider is the most appropriate action because they can provide a detailed explanation and answer specific questions the guardian may have, ensuring informed consent is truly informed.
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