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 A rationale
Hypotension, or low blood pressure, is not typically associated with nephrotic syndrome. In fact, some patients with nephrotic syndrome may experience high blood pressure.
Choice B rationale
Generalized edema, or swelling, is a common characteristic of nephrotic syndrome. It occurs due to the loss of proteins in the urine, which leads to a decrease in the amount of protein in the blood. This decrease in blood protein levels causes fluid to move from the blood vessels into the tissues, leading to swelling.
Choice C rationale
Increased urinary output is not typically associated with nephrotic syndrome. In fact, some patients may experience decreased urine output.
Choice D rationale
Bright red blood in the urine is not a typical symptom of nephrotic syndrome. Hematuria, or blood in the urine, when present in nephrotic syndrome, is usually microscopic and not visible to the naked eye.
Correct Answer is B
Explanation
Choice A rationale
Jaundice, a yellowing of the skin and eyes, is not typically a symptom of Wilms’ tumor. It is more commonly associated with conditions that cause liver dysfunction.
Choice B rationale
An abdominal mass is one of the most common symptoms of Wilms’ tumor. Parents or healthcare providers may feel a lump or swelling in the child’s abdomen.
Choice C rationale
Swollen joints are not a typical symptom of Wilms’ tumor. They are more commonly associated with conditions that affect the joints, such as juvenile arthritis.
Choice D rationale
Diarrhea is not a typical symptom of Wilms’ tumor. It is more commonly a symptom of gastrointestinal illnesses.
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