A 4-year-old patient with cystic fibrosis is hospitalized with an acute pulmonary exacerbation. When the patient is admitted, he is clutching a soiled, tattered, stuffed dog. His mother says, "He insisted on bringing the dog with him. It really is filthy.". Which nursing action is most appropriate?

Have the child choose a place in his room for the dog where he can see it but it is beyond his reach.

Tell the mother that it is all right to keep the dog with him.

Suggest to the mother that she tell the child that she will bring the dog back after taking it home to wash it.

Suggest to the mother that she choose a replacement from the stuffed animals in the playroom.

Answer and Explanation

The Correct Answer is A

Choice A rationale:

Allowing the child to have the soiled stuffed dog within sight but out of reach respects his attachment to the comfort object while maintaining hygiene standards of the hospital environment. The child's emotional well-being is crucial, and separation from a beloved item during a hospital stay can be distressing. Placing the dog in view but inaccessible helps strike a balance between comfort and infection control.

Choice B rationale:

While the mother's desire to keep the dog with the child is understandable, infection control is a concern in a hospital setting. Allowing the soiled object to remain in close proximity could compromise the child's health.

Choice C rationale:

Suggesting that the mother take the dog home to wash it and bring it back later might cause unnecessary distress for the child, who may worry about being separated from the comfort object for an extended period.

Choice D rationale:

Choosing a replacement from the playroom's stuffed animals could be unsettling for the child, as his attachment is to his specific dog. The familiarity of his own toy is likely to provide more comfort during the hospitalization. .

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Correct Answer is B

Explanation

Choice A rationale:

The identification band falling off the patient's leg is a documentation concern and doesn't require immediate action unless the patient is at risk of wandering or abduction.

Choice B rationale:

IV fluids should be changed every 24 hours to prevent bacterial growth and infection. Using fluids that are 48 hours old increases the risk of introducing infection to the patient.

Choice C rationale:

The crib rails being halfway up is not an immediate concern unless the child is at risk of falling or climbing out of the crib.

Choice D rationale:

Damp bed linen can be addressed during the next bedding change. It may not require immediate action unless the patient's skin integrity is at risk.

A. Pedal edema. B. Cardiac arrhythmias. C. Circumoral cyanosis. D. Infrequent voiding.

Correct Answer is B

Explanation

Choice A rationale:

Pedal edema is not indicative of digoxin toxicity. Digoxin toxicity primarily affects the heart's electrical activity and rhythm, not fluid accumulation in the extremities.

Choice B rationale:

Cardiac arrhythmias are a hallmark sign of digoxin toxicity. Digoxin can lead to various types of arrhythmias, such as atrial tachycardia, atrial fibrillation, and ventricular ectopy. This occurs due to the drug's effects on altering the electrical conduction in the heart.

Choice C rationale:

Circumoral cyanosis is not a typical sign of digoxin toxicity. This symptom might be seen in conditions like methemoglobinemia or respiratory distress, but it's not directly related to digoxin toxicity.

Choice D rationale:

Infrequent voiding is not a specific sign of digoxin toxicity. It could be related to various factors, such as fluid intake, renal function, or underlying medical conditions, but it's not a hallmark of digoxin toxicity.

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A 4-year-old patient with cystic fibrosis is hospitalized with an acute pulmonary exacerbation. When the patient is admitted, he is clutching a soiled, tattered, stuffed dog. His mother says, "He insisted on bringing the dog with him. It really is filthy.". Which nursing action is most appropriate?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is caring for a 2-year-old patient. Which observation requires immediate action by the nurse?

Correct Answer is B

Explanation

The nurse is caring for a pediatric patient receiving digoxin therapy. Which assessment finding would indicate digoxin toxicity?

Correct Answer is B

Explanation

Which statement, if made by a caregiver of a 2-year-old child diagnosed with cerebral palsy requires further discussion?

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