A nurse is assessing an 8-year-old child who has early indications of shock. After establishing and stabilizing the child's respirations, which of the following actions should the nurse take next?
Measure weight and height.
Insert an indwelling urinary catheter.
Initiate IV access.
Maintain ECG monitoring.
The Correct Answer is C
A. Measuring weight and height is not an immediate priority in the management of shock.
B. Inserting an indwelling urinary catheter is not a priority in the early management of shock.
C. Initiating IV access is crucial for fluid resuscitation and medication administration in a child with shock.
D. While ECG monitoring is important, it is not as immediately necessary as establishing IV access for shock management.
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Correct Answer is D
Explanation
A. A WBC of 6,000/mm³ is within the normal range (4,500-11,000/mm³), and a postoperative infection is more likely to result in an elevated WBC count.
B. Purulent nasogastric drainage is more suggestive of a gastrointestinal issue unrelated to a perforated appendix and is not a common finding post-surgery.
C. Passage of dark red stool with mucus could suggest gastrointestinal bleeding or infection, but it is not typical postoperatively after a perforated appendix.
D. After surgery for a perforated appendix, peristalsis may be absent initially due to the effects of anesthesia, bowel manipulation, or inflammation from the infection. This is a normal postoperative finding.
Correct Answer is C
Explanation
A. Rather than helping the child accept a loss of control, atraumatic care focuses on empowering the child and promoting a sense of control through participation in care and decision-making.
B. While pain management is crucial, the goal is not to have the child "accept" pain but to minimize it through interventions like distraction, pharmacologic pain relief, and comfort measures.
C. Preparing the child for unfamiliar treatments or procedures aligns with the principles of atraumatic care, which aim to reduce fear, anxiety, and physical and emotional distress. By offering developmentally appropriate explanations, the nurse helps the child feel more in control and reduces the traumatic impact of the experience.
D. Atraumatic care emphasizes maintaining parental involvement during hospitalization whenever possible. Preparing the child for separation does not align with atraumatic care principles, as separation is a source of stress that should be minimized.
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