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A nurse in an emergency department is caring for a school-age child.

Exhibits

The nurse is continuing to care for the child. Which of the following actions should the nurse plan to take? Select all that apply.

Maintain NPO status.

Administer an antipyretic.

Initiate an infusion of IV fluids.

Administer a cleansing enema.

Prepare child and parents for ostomy placement.

Educate child and parents about plan of care.

Administer an analgesic.

Administer antibiotics.

Answer and Explanation

Correct Answer : A,B,C,F,G,H

A. Maintain NPO status. The child is at risk for surgery, and maintaining NPO status reduces the risk of aspiration.
B. Administer an antipyretic. Reducing fever can improve comfort and decrease metabolic demand.
C. Initiate an infusion of IV fluids. IV fluids prevent dehydration, especially since the child has had poor oral intake and diarrhea.
D. Administer a cleansing enema. An enema is contraindicated as it may worsen abdominal inflammation or cause perforation.
E. Prepare child and parents for ostomy placement. While surgery may be needed, an ostomy is not always required for appendicitis.
F. Educate child and parents about plan of care. Providing education helps reduce anxiety and ensures understanding of the interventions.
G. Administer an analgesic. Pain management is essential for comfort and reduces physiologic stress.
H. Administer antibiotics. Antibiotics are started preoperatively to manage infection or prevent complications if perforation is suspected.

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Correct Answer is C

Explanation

A. Warm extremities: Typically, in heart failure, extremities can feel cold due to poor circulation and reduced cardiac output.
B. Frequent headaches: Headaches are not a typical sign of heart failure in children. Although they can occur in some cases due to increased intracranial pressure, they are not characteristic of heart failure.
C. Distended neck veins: Distended neck veins are a hallmark sign of right-sided heart failure. It occurs when the heart is unable to efficiently pump blood, leading to congestion and fluid retention, which can cause blood to back up into the veins, resulting in visible distention.
D. Weight loss: Weight gain due to fluid retention is more common in heart failure. Weight loss may occur in more advanced or chronic cases due to decreased appetite and fluid shifts, but weight gain is the expected finding in early stages.

A. Intake and output B. Heart rate C. Respiratory rate D. Bowel sounds E. Mucous membranes F. Weight G. Retractions H. Lung sounds I. Temperature J. Oxygen saturation

Correct Answer is ["A","B","C","G","H","I","J"]

Explanation

A. Intake and output: The infant has not fed in 8 hours and has only had 1 wet diaper during this time, which is concerning for dehydration or inadequate intake. The decreased output requires immediate follow-up to prevent further dehydration and assess fluid needs.
B. Heart rate: The heart rate of 180/min is elevated for an infant, potentially indicating dehydration, fever, or respiratory distress. Tachycardia can also signify compensation for hypoxia.
C. Respiratory rate: A respiratory rate of 60/min is elevated for an infant and indicates respiratory distress, compounded by retractions and diminished lung sounds in the right lobes.
D. Bowel sounds: Active bowel sounds in all four quadrants are a normal finding and do not indicate an acute issue.
E. Mucous membranes: While dry mucous membranes confirm dehydration, they are not the highest priority compared to respiratory distress or oxygen saturation.
F. Weight: Weight loss from 9 lb to 8 lb 8 oz is concerning for chronic dehydration or inadequate nutrition, but it does not require immediate action compared to acute respiratory and oxygenation issues.
G. Retractions: Moderate substernal and intercostal retractions are indicative of respiratory distress. This requires immediate follow-up to assess the severity of the distress and initiate appropriate interventions, such as supplemental oxygen or further evaluation.
H. Lung sounds: Diminished lung sounds in the right lobes and occasional coarse crackles are concerning for a respiratory infection or condition such as pneumonia or bronchiolitis. Immediate follow-up is required to assess the cause and severity of the respiratory findings.
I. Temperature: The infant has a fever, which is concerning, especially with poor feeding and lethargy. Fever in an infant can indicate a serious infection (e.g., sepsis, urinary tract infection, or pneumonia) that requires immediate medical attention and further investigation.
J. Oxygen saturation: An oxygen saturation of 92% is low for an infant, indicating hypoxia, likely due to respiratory compromise. Immediate intervention (e.g., oxygen therapy) is necessary to prevent further deterioration.

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A nurse in an emergency department is caring for a school-age child. Exhibits The nurse is continuing to care for the child. Which of the following actions should the nurse plan to take? Select all that apply.

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is assessing a child who has heart failure. Which of the following clinical manifestations should the nurse expect?

Correct Answer is C

Explanation

Correct Answer is ["A","B","C","G","H","I","J"]

Explanation

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A nurse in an emergency department is caring for a school-age child.

Exhibits

The nurse is continuing to care for the child. Which of the following actions should the nurse plan to take? Select all that apply.