Which client on an acute care pediatric unit requires the nurse’s immediate attention?
An 18-month-old client who had a cleft palate repair and is crying in pain.
A 12-year-old client who had an appendectomy and refuses to ambulate.
An 8-year-old client who had a tonsillectomy and is swallowing frequently.
A 15-year-old client who has an IV infusion and reports pain at the insertion site.
The Correct Answer is C
Choice A rationale
While pain management is important following a cleft palate repair, it does not typically require immediate attention. Pain can be managed with appropriate analgesics and does not typically present an immediate risk to the patient’s health.
Choice B rationale
A patient refusing to ambulate following an appendectomy does not typically require immediate attention. Encouraging mobility is important for recovery, but refusal to ambulate does not present an immediate risk to the patient’s health.
Choice C rationale
Frequent swallowing following a tonsillectomy could indicate post-operative bleeding, which requires immediate attention. Post-tonsillectomy hemorrhage can be a life-threatening condition that requires immediate intervention.
Choice D rationale
While pain at the site of an IV infusion should be addressed, it does not typically require immediate attention unless there are signs of infection or infiltration. It does not present an immediate risk to the patient’s health.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Choice A rationale
While pain management is important following a cleft palate repair, it does not typically require immediate attention. Pain can be managed with appropriate analgesics and does not typically present an immediate risk to the patient’s health.
Choice B rationale
A patient refusing to ambulate following an appendectomy does not typically require immediate attention. Encouraging mobility is important for recovery, but refusal to ambulate does not present an immediate risk to the patient’s health.
Choice C rationale
Frequent swallowing following a tonsillectomy could indicate post-operative bleeding, which requires immediate attention. Post-tonsillectomy hemorrhage can be a life-threatening condition that requires immediate intervention.
Choice D rationale
While pain at the site of an IV infusion should be addressed, it does not typically require immediate attention unless there are signs of infection or infiltration. It does not present an immediate risk to the patient’s health.
Correct Answer is C
Explanation
Choice A rationale
While it’s true that bone marrow can be lost through a fracture, this is not specific to fractures of the epiphyseal plate.
Choice B rationale
The healing time for fractures in children and adults can vary depending on many factors, but it’s not accurate to say that fractures in children take longer to heal than fractures in adults.
Choice C rationale
Normal bone growth can indeed be affected by a fracture of the epiphyseal plate. The epiphyseal plate, or growth plate, is the area of growing tissue near the ends of the long bones in children and adolescents. When a fracture occurs at the epiphyseal plate, it can disrupt the normal growth of the bone and lead to deformities.
Choice D rationale
While calcium is important for bone health, increasing a child’s calcium intake to 3,000 milligrams daily is not typically recommended as part of the treatment or management of a fracture.
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