A nurse in an emergency department is caring for a school-age child.
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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["B","D","E"]
Explanation
Heart rate 162/min: Elevated for a 4-month-old at rest; tachycardia can indicate dehydration, fever, or stress.
Spits up forcefully after feedings: Forceful vomiting can suggest gastroesophageal reflux disease (GERD) or pyloric stenosis.
Small, soft midline bulge: Likely an umbilical hernia; may need monitoring or intervention if persistent or large.
Correct Answer is ["A","B","C","D"]
Explanation
Findings that require immediate follow-up:
- Generalized muscle weakness noted in bilateral lower extremities: This could indicate a neurological or muscular issue, such as Guillain-Barré Syndrome (GBS), which is a concern after a viral infection or vaccination. This requires further investigation and close monitoring for any signs of progression, such as worsening weakness or respiratory involvement.
- Child reports pain in legs on palpation, rates pain as 5 on a scale of 0 to 10: This pain could be indicative of muscle cramping or weakness, which may be associated with GBS or another neurological condition. Pain in combination with muscle weakness should be followed up closely.
- Abdomen slightly firm, bowel sounds hypoactive, and reports last bowel movement was 3 days ago: This could suggest constipation or a gastrointestinal issue. However, the gastrointestinal symptoms may be secondary to the muscle weakness (if part of a systemic condition like GBS), and should be monitored, but it’s not as urgent as the neurological findings.
Findings that do not require immediate follow-up:
- Patellar deep tendon reflexes 1+ bilaterally: A 1+ reflex is on the lower end of normal and does not indicate a severe problem by itself.
- Child is awake and alert, responds appropriately to questions: This is a reassuring sign and does not require immediate follow-up.
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