The nurse is caring for a 2-year-old patient. Which observation requires immediate action by the nurse?
The identification band has fallen off the patient's leg.
The IV fluid is 48 hours old.
The crib rails are halfway up.
The bed linen is damp.
The Correct Answer is B
Choice A rationale:
The identification band falling off the patient's leg is a documentation concern and doesn't require immediate action unless the patient is at risk of wandering or abduction.
Choice B rationale:
IV fluids should be changed every 24 hours to prevent bacterial growth and infection. Using fluids that are 48 hours old increases the risk of introducing infection to the patient.
Choice C rationale:
The crib rails being halfway up is not an immediate concern unless the child is at risk of falling or climbing out of the crib.
Choice D rationale:
Damp bed linen can be addressed during the next bedding change. It may not require immediate action unless the patient's skin integrity is at risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice A rationale:
Monitoring the patient's breathing pattern at 15-minute intervals is crucial in an unconscious patient who may have ingested alcohol or drugs, as it helps assess their respiratory status. This intervention ensures early detection of any respiratory distress and guides necessary interventions.
Choice B rationale:
Inserting an indwelling Foley catheter for straight drainage is appropriate for unconscious patients to monitor their urinary output and renal function. This helps prevent urinary retention and complications related to inadequate urine elimination.
Choice C rationale:
Administering IV D5/45 NS at 100 mL/hr is a suitable intervention to maintain the patient's fluid and electrolyte balance. It prevents dehydration and supports hemodynamic stability.
Choice D rationale:
The nurse should question the prescription of syrup of ipecac. Ipecac is no longer recommended for use in cases of poisoning due to its potential to cause adverse effects like aspiration, electrolyte imbalances, and delayed treatment. Activated charcoal or gastric lavage may be more appropriate in this situation.
Correct Answer is A
Explanation
Choice A rationale:
Expiratory wheezing is characteristic of asthma exacerbation. It indicates airway constriction and narrowing, leading to difficulty in exhaling and resulting in a high-pitched sound during expiration.
Choice B rationale:
Inspiratory crackle is not typically associated with asthma. Crackles are often heard in conditions involving fluid-filled airways, such as pneumonia.
Choice C rationale:
Expiratory grunting is not a common finding in asthma. Grunting sounds may be present in infants with respiratory distress, indicating the difficulty they experience while exhaling.
Choice D rationale:
Inspiratory stridor is not a usual manifestation of asthma. Stridor is more commonly related to upper airway obstruction, often seen in croup or epiglottitis.
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