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The client is a 12-year-old male who sustained a gunshot wound to his abdomen. He had a surgical repair of a perforated small intestine 4 days ago. The client is 112.4 Ib. (51 kg). He has a nasogastric tube, a left femoral central line for fluids, and a right hand peripheral intravenous line.

Review H and P, laboratory results, flow sheet, and orders.

The nurse receives the report from the lab and documents the intake and output for 1600.

Based on the client's information at 1600, what symptoms should the nurse look for? Select all that apply.

Edema

Irritability

Fatigue

Dry skin

Intense thirst

Muscle weakness

Hypertension

Answer and Explanation

Correct Answer : A,D,E,F

A. Edema can be a symptom to watch for, as it may indicate fluid retention or imbalance, especially in a client who has received intravenous fluids.

D. Dry skin may be a symptom to observe, as it could suggest dehydration or fluid imbalances.

E. Intense thirst is a symptom to be alert for, as it may be an indication of dehydration or an electrolyte imbalance.

F. Muscle weakness is a potential symptom to monitor for, as it could be related to electrolyte imbalances or other complications following surgery and injury.

B, C, and G are not the primary symptoms to expect based on the client's information and history, but they should still be monitored as part of routine assessment. Irritability and fatigue can be nonspecific symptoms that may occur in various clinical situations. Hypertension may or may not be a symptom, and it is essential to assess the client's blood pressure in the context of their overall condition.

The client's history and the presence of medical devices and surgical intervention indicate the need for close monitoring of fluid balance and electrolyte status.

Nursing Test Bank

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Naxlex Comprehensive Predictor Exams

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Correct Answer is C

Explanation

A. The mother being a single parent and living with her parents may have an impact on the family dynamics and support system but is not the most significant finding when it comes to addressing the baby's sleep issues.

B. The baby being irritable during feedings is important information and should be addressed, but it may not be the most significant finding when it comes to the baby's sleep patterns.

C. The diaper area shows severe skin breakdown.

Severe skin breakdown in the diaper area can be indicative of several issues, including frequent diaper changes, diaper rash, or potential underlying health concerns. This finding suggests that the infant may have discomfort or pain related to the diaper area, which could be contributing to the baby's nighttime awakenings and sleep disturbances.

D. The infant's formula being changed twice may be relevant, but it is not as significant as severe skin breakdown, which can indicate immediate discomfort for the baby.

A. Point of care blood glucose B. Check pedal pulses every 4 hours C. Give lactated Ringers intravenously at 66 ml/hr while NPO D. Vital signs every 4 hours E. Nothing by mouth F. Admit to the pediatric floor for observation G. Check dressing every 15 minutes for 1 hour and then every hour for

Correct Answer is ["B","C"]

Explanation

B. Check pedal pulses every 4 hours: This order should be questioned because after a ventricular septal defect closure, it is essential to assess and monitor peripheral pulses frequently, especially in the immediate post-catheterization period. Checking pedal pulses every 4 hours may not provide adequate monitoring and could potentially lead to delayed detection of complications.

C. Give lactated Ringers intravenously at 66 ml/hr while NPO: This order should be questioned because it specifies a continuous intravenous infusion of lactated Ringer's solution, but the patient is listed as "Nothing by mouth" (E). In cases where a patient is NPO, it's important to clarify the rationale for the intravenous fluid rate and consider whether it's appropriate, especially after a cardiac catheterization procedure.

The other orders are appropriate or necessary for the post-catheterization care of a child with a closed ventricular septal defect:

A. Point of care blood glucose: Monitoring blood glucose levels is relevant in post-catheterization care.

D. Vital signs every 4 hours: Monitoring vital signs is standard post-catheterization care.

F. Admit to the pediatric floor for observation: This order is appropriate for post-catheterization observation.

G. Check dressing every 15 minutes for 1 hour and then every hour: Frequent dressing checks are important for assessing and preventing bleeding or other complications at the catheterization site.

H. Place the child on a continuous cardiopulmonary monitor: Continuous monitoring is important for early detection of any cardiopulmonary issues in the post-catheterization period.

In summary, monitoring peripheral pulses and the appropriateness of intravenous fluids in relation to NPO status should be questioned in this context.

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Naxlex Comprehensive Predictor Exams

A mother brings her 3-month-old infant to the clinic because the baby does not sleep through the night. Which finding is most significant in planning care for this family?

Correct Answer is C

Explanation

Correct Answer is ["B","C"]

Explanation

The nurse is assessing a child with acute glomerulonephritis who presents to the clinic with increased fatigue, facial puffiness, decreased appetite. The child's urine sample is dark yellow in color. Which additional finding should the nurse report to the healthcare provider?

The parents of a 14-month-old child who is hospitalized due to febrile seizures tell the nurse that they fear their child will have lifelong seizures. Which information should the nurse convey to these parents?

The mother of an 11-year-old boy who has juvenile idiopathic arthritis tells the nurse, "I really don't want my son to become dependent on pain medication, so I only allow him to take it when he is really hurting." Which information is most important for the nurse to provide this mother?

When providing care for a child who is in balanced suspension skeletal traction using a Thomas splint and Pearson attachment to the right femur, which intervention is most important for the nurse to implement?

The nurse is assessing a 6-month-old infant. Which response requires further evaluation by the nurse?

The nurse begins collecting the medical history of a child when the child screams and tries to hide behind the parent, dropping a stuffed toy. Which intervention should the nurse implement?

An infant born 2 days ago has not passed a meconium stool and begins to vomit bilious secretions. Which action should the nurse take first?