Exhibits
The parents are at the bedside and state that each parent thought the other parent was watching the child. They are not sure how long he was in the pool or how he might have fallen in. The temperature of the pool was cool as the temperature outside was about 64 °F (17.8 °C).
Placed a cervical collar with the assistance of the physician. The child's pulse is 121 beats/minute, the airway is patent, and there are no signs of any bleeding.
Review H and P, nurse's note, laboratory results, orders, and imaging studies. What complications should the nurse monitor for in the next 6 to 8 hours? Select all that apply.
Cerebral edema
Acute asphyxia
Hypertension
Respiratory distress
Hyperthermia
Subdural hemorrhage
Correct Answer : A,B,D,F
A) Cerebral edema: Brain injury or trauma can lead to swelling and increased intracranial pressure.
B) Correct- Near- drowning causes acute asphyxia because it prevents the person from breathing in oxygen and exhaling carbon dioxide. Asphyxia is a condition where the body is deprived of oxygen, which can lead to loss of consciousness, brain injury, or death.
C) Incorrect- Hypertension is not a common complication following near-drowning. The focus should be on potential brain injuries and respiratory distress.
D) Correct- Near-drowning can lead to aspiration of water or other substances, which can result in respiratory distress.
E) Incorrect- hyperthermia is not likely to occur in this case because the child was exposed to cold water.
F) Correct- Head trauma can lead to bleeding within the brain, such as a subdural hemorrhage.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A,B,C,D,E
Explanation
A) This is because the client is experiencing an allergic reaction to piperacillin, which can be life-threatening. The nurse should stop the infusion immediately to prevent further exposure to the drug and assess vital signs to monitor for signs of anaphylaxis, such as hypotension, tachycardia, wheezes, or stridor.
B) Assessing vital signs is a priority to determine the severity of the reaction and the client's overall condition.
C) The nurse should contact the healthcare provider to report the situation and obtain orders for treatment, such as antihistamines, corticosteroids, or epinephrine.
D) The nurse should initiate an adverse event report to document the incident and follow the facility's protocol for reporting medication errors.
E) The nurse should also document the reaction to the drug in the client's chart and notify the pharmacy to avoid future administration of piperacillin or related antibiotics.
Correct Answer is D
Explanation
A.While pain management is important, it is not the most critical intervention compared to monitoring for bleeding, which can be life-threatening.
B.Teaching the client how to use incentive spirometry is important for improving lung function and preventing complications like atelectasis. However, in the context of a pulmonary embolism (PE), the immediate priority is to monitor for signs of increased bleeding due to the anticoagulant or thrombolytic therapy often used to treat PE. This is crucial to prevent potentially life-threatening complications.
C.Confusion and restlessness could indicate hypoxia, which is important to monitor in a PE patient. However, the immediate risk of bleeding due to anticoagulation therapy takes precedence.
D.Patients with a pulmonary embolism are typically treated with thrombolytic or anticoagulant therapy to prevent further clot formation and to help dissolve the existing clot. Anticoagulants significantly increase the risk of bleeding, making it crucial to monitor for signs of increased bleeding as a priority in the plan of care.
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