A nurse is assisting with planning care for a school-age child on the pediatric unit.
div id="exhibits">ExhibitsComplete 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 C
Explanation
A. Reinforce with the guardians to avoid discussing death with the child's siblings: Avoiding the discussion of death with the child's siblings can create confusion and anxiety. It's important to foster open communication and allow siblings to process their emotions about the situation in an age-appropriate manner.
B. Guide discussions with the child about death: Discussions about death should be handled delicately, considering the child’s age and understanding; this should be done in partnership with the family and healthcare providers.
C. Use a calm tone of voice when speaking with the child: A calm, reassuring tone of voice is essential when interacting with a child in palliative care. This helps provide comfort, reduces anxiety, and establishes a sense of safety for the child during a difficult time.
D. Encourage the guardians to seek a second opinion about their child's diagnosis:
Seeking a second opinion may be an option in some situations, but in the context of palliative care, the focus is typically on comfort and quality of life rather than pursuing further curative treatments.
Correct Answer is D
Explanation
A. Position the child sitting with their buttocks at the edge of the table: This position is not appropriate for bone marrow aspiration. It does not provide adequate access to the iliac crest, which is the common site for bone marrow collection in children.
B. Position the child side-lying to expose the vertebrae: The vertebrae are not typically used for bone marrow aspiration. The iliac crest (the top of the hip bone) is the preferred site, and side-lying does not expose this area appropriately for the procedure.
C. Place the child supine with legs flexed outward into a frog-like position: This position is commonly used for procedures such as abdominal or pelvic examinations but does not provide the best access for bone marrow aspiration from the iliac crest.
D. Place the child in prone position to expose the posterior iliac crest: The prone position with the back exposed allows the posterior iliac crest to be properly accessed for bone marrow aspiration. This is the correct position for the procedure in children.
Complete the following sentence by using the lists of options.
The nurse should recommend to