A 10-year-old patient has returned to her room after a surgical procedure. Which observation should take priority for nursing action?
Absence of bowel sounds.
Pulse rate of 150 per minute.
Blood-tinged urine from the ureteral catheter.
Serosanguineous drainage on her incisional dressing.
The Correct Answer is B
Choice A rationale:
Absence of bowel sounds is not a priority in this situation as it is common for bowel sounds to be absent temporarily after surgery due to anesthesia and decreased peristalsis. It should be monitored, but it doesn't require immediate nursing action.
Choice B rationale:
A pulse rate of 150 per minute is a significant finding in a 10-year-old patient after surgery. Tachycardia can indicate pain, anxiety, hypovolemia, or other postoperative complications. Immediate nursing action is required to assess the cause and initiate appropriate interventions.
Choice C rationale:
Blood-tinged urine from the ureteral catheter might be expected after a surgical procedure involving the urinary system. While it requires monitoring, it is less urgent than addressing a high pulse rate in a postoperative child.
Choice D rationale:
Serosanguineous drainage on the incisional dressing is a normal finding in the immediate postoperative period. It indicates minor oozing of blood mixed with serous fluid. While it requires monitoring, it is not as concerning as the elevated pulse rate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Have a child life specialist explain the procedure using a doll.
Choice A rationale:
Having a child life specialist explain the procedure using a doll is the best approach for preparing a 4-year-old for a bone marrow aspiration. This method utilizes play therapy to help the child understand the procedure in a developmentally appropriate and non-threatening way.
Choice B rationale:
Giving the client color handouts might not effectively engage a 4-year-old's attention and understanding. Young children often benefit more from interactive and visual methods like using a doll.
Choice C rationale:
Telling the client that other children have had the procedure might not alleviate the child's anxiety or fear. Concrete explanations and visual aids are more effective in reducing anxiety and helping the child cope.
Choice D rationale:
Allowing the patient to watch a video of the procedure on another child could potentially increase anxiety and fear. Children might not fully comprehend the video and could misinterpret it, leading to more distress. Interactive methods are more effective.
Correct Answer is B
Explanation
Choice A rationale:
Educating caregivers on sensory impairment is important in the care of a child with myelomeningocele, but the priority is to prevent infection. The exposed spinal cord and tissue are at risk of infection.
Choice B rationale:
Preventing infection is the priority for a child with myelomeningocele. The neural tube defect exposes the spinal cord, making the child susceptible to infections that can lead to serious complications.
Choice C rationale:
Correction of joint contractures is important in the overall care of a child with myelomeningocele, but preventing infection takes precedence. Joint contractures can be managed over time, while infection can quickly escalate.
Choice D rationale:
Measuring daily head circumference is essential for assessing hydrocephalus in a child with myelomeningocele, but preventing infection is more urgent. Infection can cause rapid deterioration, while changes in head circumference might be gradual.
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