A nurse is caring for a 7-year-old male client who sustained a traumatic injury to the left leg after being struck by a lawnmower while playing outside.
Complete the diagram by dragging from the choices area to specify which condition the client is most likely experiencing, two actions the nurse should take to address that condition, and two parameters the nurse should monitor to assess the client's progress.
The Correct Answer is []
TRALI is a life-threatening condition associated with blood transfusion. The client’s symptoms, including trauma and low hemoglobin, indicate the need for transfusion. TRALI can cause acute respiratory distress shortly after transfusion. Early intervention can improve outcomes. Recognizing the signs of TRALI is essential in such scenarios.
Rationale for actions
Administer oxygen: Oxygen supplementation can help manage hypoxemia associated with TRALI. It ensures adequate oxygenation during respiratory distress. Monitor for respiratory distress: Continuous assessment helps detect worsening symptoms. Early detection can prompt timely intervention. Rationale for parameters: Oxygen saturation: Monitoring SpO2 provides real-time information on the patient’s oxygenation status. It helps determine the effectiveness of oxygen therapy. Heart rate: Tachycardia can indicate worsening respiratory distress or hypoxemia. Monitoring heart rate is crucial for early detection of complications.
Rationale for incorrect conditions
Transfusion-associated circulatory overload (TACO): TACO involves fluid overload, leading to cardiac symptoms. However, this client’s presentation suggests acute lung injury, not fluid overload. Incorrect conditions (others): Abandonment: Not applicable as the client was brought to the hospital and received care. Physical abuse: No evidence of physical abuse in this case. Self-neglect: The client is a child, and the injury was accidental, not due to neglect. The parents brought him to the hospital promptly.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A rationale
Assessing serum potassium levels every 4 hours is essential for clients receiving insulin to treat hyperkalemia. Insulin promotes the uptake of potassium into cells, potentially leading to hypokalemia. Frequent monitoring ensures prompt detection of abnormal potassium levels, enabling timely intervention.
Choice B rationale
Although glucose monitoring is important, it is not the priority. Insulin administration affects potassium levels more significantly in this scenario, and glucose level fluctuations are typically less life-threatening than potassium imbalances.
Choice C rationale
Monitoring intake and output is standard practice for managing clients with electrolyte imbalances. However, it does not directly address the primary concern of potassium level fluctuations caused by insulin administration.
Choice D rationale
A daily 12-lead electrocardiogram may provide useful information on the cardiac effects of electrolyte imbalances but is less immediate in detecting rapid potassium changes than frequent serum potassium measurements.
Correct Answer is A
Explanation
Choice A rationale: Acute appendicitis is most likely based on the history of sudden onset of severe abdominal pain localized to the right lower quadrant, nausea, vomiting with green bile, and tenderness on physical examination. The ultrasound findings of right lower quadrant tenderness further support this diagnosis. The client's vital signs, including tachycardia and tachypnea, are consistent with the stress and pain caused by acute appendicitis.
Choice B rationale: Ectopic pregnancy is less likely as the client has a negative pregnancy test and reports regular menstrual cycles with her last period occurring one week ago. Additionally, her symptoms are more typical of appendicitis.
Choice C rationale: Ovarian cyst rupture would typically present with sudden onset of pelvic pain, often associated with menstrual irregularities or a history of ovarian cysts. However, the client's presentation and diagnostic results strongly point towards acute appendicitis.
Choice D rationale: Acute gastritis generally presents with epigastric pain, nausea, and vomiting. However, the localization of pain to the right lower quadrant and the ultrasound findings make appendicitis a more likely diagnosis in this case.
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