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 A
Explanation
Choice A rationale
A urine specific gravity of 1.034 is higher than the normal range (1.002-1.030), indicating that the urine is more concentrated due to a lack of hydration.
Choice B rationale
A bounding pulse is not typically associated with dehydration. Dehydration more commonly results in a weak, rapid pulse.
Choice C rationale
A blood pressure reading of 46/94 mm Hg is not indicative of dehydration. Dehydration often leads to low blood pressure.
Choice D rationale
Distended neck veins are not a typical sign of dehydration. Dehydration can lead to decreased blood volume, which would not cause distension of the neck veins.
Correct Answer is A
Explanation
Choice A rationale
Activated charcoal is often used in cases of drug overdose or poisoning, including aspirin ingestion. It works by binding to the drug or toxin in the stomach, preventing it from being absorbed into the body. This makes activated charcoal an effective treatment for aspirin overdose in a toddler.
Choice B rationale
A chelating agent is a substance that can bind to heavy metals in the body, helping to remove them. While useful in cases of heavy metal poisoning, it would not be the first choice for an aspirin overdose.
Choice C rationale
Acetylcysteine is an antidote for acetaminophen (Tylenol) overdose, not aspirin. It works by replenishing glutathione, a substance that helps to detoxify the liver.
Choice D rationale
Digoxin immune FAB is used to treat digoxin toxicity. Digoxin is a medication used to treat heart conditions, and it is not related to aspirin.
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