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A nurse is caring for a 15-year-old adolescent.

Exhibits
Choose words from the choices below to fill in each blank in the following sentence.

The nurse reviews the EMR and determines that the adolescent is at risk for developing which of the following complications?

The adolescent is at risk for developing _ and _

muscle cramps

pneumothorax

dehydration

anemia

Answer and Explanation

Correct Answer : B,C

The adolescent is at risk for developing Target 1: dehydration and Target 2: pneumothorax.

Rationale:

Dehydration: The adolescent's fever, increased respiratory rate, and decreased oral intake put them at risk for dehydration.
Pneumothorax: In severe pneumonia, there is a risk of lung collapse or pneumothorax, especially in adolescents.

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Correct Answer is ["C","D"]

Explanation

A. The child should avoid tub baths or submerging in water for several days post-procedure to reduce the risk of infection and keep the catheter site dry; sponge baths are usually recommended.

B. Keeping the child home for an entire week may be excessive; the duration of home care typically depends on the child's recovery, and many children can return to school sooner if they feel well.

C. Offering clear liquids for the first 24 hours helps ensure the child stays hydrated and allows for easier digestion following anesthesia or sedation.

D. Giving acetaminophen for discomfort is appropriate, as it can help manage any pain or discomfort the child may experience after the procedure, and is usually a recommended practice.

A. Instructing the client to eat foods that are low in potassium. B. Repeat the dose if the client spits it out. C. Measuring apical pulse rate for 30 seconds before administration. D. Evaluating the client for nausea, vomiting, and anorexia.

Correct Answer is C

Explanation

A. Clients on digoxin should actually have an adequate intake of potassium, as low potassium levels can increase the risk of digoxin toxicity.

B. If a pediatric client spits out digoxin, the dose should not be repeated automatically; instead, the nurse should assess the situation and follow the facility's protocol regarding missed doses.

C. Measuring the apical pulse for one full minute before administering digoxin is critical; if the pulse is below the established threshold (usually <60 bpm for children), the medication should be held and the provider notified.

D. While evaluating for nausea, vomiting, and anorexia is important, it is not an appropriate immediate action before administering the medication. The priority action is to assess the apical pulse.

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A nurse is providing discharge instructions to the parent of a 10-year-old child following a cardiac catheterization. Which of the following instructions should the nurse include?

Correct Answer is ["C","D"]

Explanation

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Correct Answer is C

Explanation

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