A nurse is assisting in the care of a group of children on a pediatric medical surgical unit. Which of the following children should the nurse collect data from first?

A toddler who has periorbital cellulitis and has an axillary temperature of 37.6° C (99.7° F)

An adolescent who has influenza and reports a headache of 6 on a scale of 0 to 10

An infant who had a pyloromyotomy 12 hr ago and spit up after the last feeding

A child who had a cast placed 4 hr ago and reports numb in the affected extremity

Answer and Explanation

The Correct Answer is D

A. A toddler who has periorbital cellulitis and has an axillary temperature of 37.6°C (99.7°F): A mild temperature in the context of periorbital cellulitis is expected and not an immediate emergency. Although periorbital cellulitis can be serious, this temperature alone does not demand immediate action over other critical symptoms.

B. An adolescent who has influenza and reports a headache of 6 on a scale of 0 to 10: A headache with influenza is common and requires monitoring, but unless there are signs of severe neurological involvement, it is not the highest priority compared to potential circulatory compromise.

C. An infant who had a pyloromyotomy 12 hr ago and spit up after the last feeding: Mild vomiting or spitting up is common following a pyloromyotomy and is not unusual within the first 24 hours postoperatively. It generally does not require immediate intervention unless persistent or worsening.

D. A child who had a cast placed 4 hr ago and reports numbness in the affected extremity: Numbness may indicate impaired circulation or nerve compression, a sign of possible compartment syndrome. This is a surgical emergency that can result in permanent damage if not promptly assessed and treated.

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Correct Answer is A

Explanation

A. Frequent swallowing: Frequent swallowing after a tonsillectomy can be a sign of active bleeding from the surgical site. Even if bleeding is not visible, the child may be swallowing blood, which can lead to significant hemorrhage. This is the priority finding that requires immediate intervention.

B. Report of sore throat: A sore throat is an expected and normal finding after a tonsillectomy due to surgical trauma and healing. It does not represent an urgent or life-threatening complication.

C. Dark brown blood between the teeth: Dark brown blood suggests old, minimal bleeding and is not as concerning as active bright red bleeding. While it should be monitored, it is not the priority compared to signs of active hemorrhage.

D. Coffee-ground appearance of emesis: Coffee-ground emesis suggests the presence of digested blood, often from swallowed blood, and while concerning, it is a secondary finding. Frequent swallowing points more directly to active bleeding, which is more immediately life-threatening.

A. A client who has a urinary tract infection B. A client who has a spinal cord injury C. A client who has acute appendicitis D. A client who has a torn rotator cuff

Correct Answer is B

Explanation

A. A client who has a urinary tract infection: A urinary tract infection is generally straightforward to manage with antibiotics and does not usually require input from multiple disciplines unless complications arise.

B. A client who has a spinal cord injury: A spinal cord injury often involves complex care needs requiring input from several disciplines, including physical therapy, occupational therapy, nursing, social work, and nutrition services. Coordinated planning is essential to optimize recovery and long-term management.

C. A client who has acute appendicitis: Acute appendicitis typically requires prompt surgical intervention but does not usually require an interprofessional conference unless there are unusual complications or comorbidities.

D. A client who has a torn rotator cuff: A torn rotator cuff is typically managed with surgical repair or physical therapy. While it may involve multiple providers, it generally does not require a full interprofessional conference unless extensive rehabilitation needs are anticipated.

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A nurse is assisting in the care of a group of children on a pediatric medical surgical unit. Which of the following children should the nurse collect data from first?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is collecting data from a child who is 1 hr postoperative following a tonsillectomy. Which of the following findings is the nurse's priority?

Correct Answer is A

Explanation

A nurse is assisting with the plan of care for a group of clients. Which of the following clients should the nurse recommend for an interprofessional conference?

Correct Answer is B

Explanation

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