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 B
Explanation
Choice B rationale
Gelatin is part of a clear liquid diet. This type of diet is often prescribed before medical procedures or tests, or for patients with certain digestive issues. It consists of liquids and foods that are clear and liquid at room temperature.
Choice A rationale
Yogurt is not part of a clear liquid diet. It is a dairy product and is not clear or liquid at room temperature.
Choice C rationale
Strained soup might be allowed on a full liquid diet, but it is not part of a clear liquid diet. Only the broth of the soup, which is clear and liquid at room temperature, would be allowed.
Choice D rationale
Pureed fruit is not part of a clear liquid diet. While it is a liquid at room temperature, it is not clear.
Correct Answer is B
Explanation
Choice A rationale
Shingles, also known as herpes zoster, is a viral infection that causes a painful rash and is caused by the varicella-zoster virus, the same virus that causes chickenpox.
Choice B rationale
Tinea pedis is a foot infection due to a dermatophyte fungus. It is the most common dermatophyte infection and is particularly prevalent in hot, tropical, urban environments. Interdigital involvement is most commonly seen (this presentation is also known as athlete’s foot, although some people use the term for any kind of tinea pedis).
Choice C rationale
Fever blister, also known as cold sores, are caused by the herpes simplex virus. They are small, fluid-filled blisters that develop on the lips or around the mouth.
Choice D rationale
Pinworms are a type of parasite that lives in the lower intestine of humans. They are tiny, narrow worms. They are white and less than a half-inch long.
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