A nurse is assisting with planning care for a school-age child on the pediatric unit.
Complete the following sentence by using the lists of options.
The nurse should recommend to
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
Rationale for Correct Choices:
- Check the child's oropharynx: The child has had a tonsillectomy and is showing signs of possible bleeding, indicated by the small amount of bleeding in the posterior pharynx and bright red emesis (vomiting of blood). The nurse should check the oropharynx to assess the amount and source of the bleeding, as this could indicate a complication post-surgery.
- Obtaining a set of vital signs: After vomiting bright red emesis, it is crucial to assess the child's vital signs to monitor for signs of bleeding or shock. Changes in vital signs, especially increased heart rate or decreased blood pressure, could indicate significant blood loss.
Rationale for Incorrect Choices:
- Offer the child a red popsicle: Red-colored foods are generally avoided post-tonsillectomy as they can obscure or be mistaken for blood. More importantly, offering anything by mouth is contraindicated during active bleeding due to the risk of aspiration and potentially dislodging clots.
- Place the child in a supine position: The child should be positioned in a way that allows for the drainage of blood and secretions, ideally with the head elevated. Placing the child in a supine position could cause blood to pool in the throat, increasing the risk of aspiration.
- Encouraging the child to cough and deep breathe: Encouraging coughing and deep breathing immediately after tonsillectomy is not recommended, as it could dislodge a clot or exacerbate bleeding.
- Requesting a prescription for codeine: Although the child is experiencing some pain (rated 3/10), the primary concern at this point is bleeding, not pain. Pain management should be adjusted but the focus should be on addressing the bleeding first.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is {"dropdown-group-1":"C","dropdown-group-2":"C"}
Explanation
Rationale for Correct Choices:
- Consult the child life specialist for guidance: A child life specialist can help the parent navigate the difficult conversation with their adolescent, providing strategies for addressing sensitive topics like metastasis and death.
- Reinforce teaching to the parent regarding the adolescent's potential emotional responses: Educating the parent on common emotional responses helps them prepare for and better support their adolescent through this challenging time.
Rationale for Incorrect Choices:
- Encourage the parent to hide their emotions from their adolescent: Hiding emotions can create barriers to trust and communication, which can make the adolescent feel isolated or confused.
- Instruct the parent to withhold the test results from their adolescent: Withholding important information can prevent the adolescent from understanding their condition and making informed decisions about their care.
- Discourage the parent from discussing the possibility of death with their adolescent: Avoiding discussions about death can prevent the adolescent from processing their emotions and understanding the reality of their situation.
- Collaborate with the RN to initiate a referral for admission to hospice care: Hospice care should only be considered after emotional support and clear communication have been established, not prematurely without addressing emotional needs first.
Correct Answer is D
Explanation
A. Edema: Edema can occur with heart failure, but it is not specifically an indication of digoxin toxicity. Digoxin helps improve heart function and reduce edema, so it is not a direct sign of toxicity.
B. Jaundice: Jaundice may indicate liver dysfunction, but it is not a common sign of digoxin toxicity. Liver function issues can arise from various causes, but jaundice is not typically associated with digoxin toxicity.
C. Purulent sputum: Purulent sputum suggests an infection, such as pneumonia, and is not related to digoxin toxicity. This symptom requires further evaluation for respiratory infections, not digoxin-related issues.
D. Bradycardia: Bradycardia (a slow heart rate) is a classic sign of digoxin toxicity. Digoxin can slow the heart rate by affecting the electrical conduction system of the heart, and bradycardia is a key indicator of overdose or toxicity in infants and children taking this medication.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.