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 B
Explanation
Choice A rationale
Crushing zolpidem to increase absorption is inappropriate because it is a controlled-release medication. Crushing the tablet would disrupt the controlled-release mechanism, leading to rapid absorption, increased side effects, and potentially dangerous consequences.
Choice B rationale
Taking zolpidem before bedtime is correct because it is a medication prescribed for insomnia. It helps the patient fall asleep more quickly by acting on the central nervous system to induce sleep, and it should be taken when the patient is ready to sleep.
Choice C rationale
Administering zolpidem with a meal is not recommended. Food can delay the absorption of the medication, reducing its effectiveness in helping the patient fall asleep promptly.
Choice D rationale
Storing zolpidem at room temperature is correct, but it is not a critical point of patient education. The emphasis should be on taking the medication as prescribed and understanding its purpose and potential side effects.
Correct Answer is A
Explanation
Choice A rationale
Withholding the dose is the safest action to avoid potential overdose or toxicity. Digoxin has a narrow therapeutic window, and administering an additional dose without knowing how much was absorbed could lead to dangerous side effects.
Choice B rationale
Administering a half dose now is not recommended because it is unclear how much of the original dose was absorbed. This could result in either an insufficient dose or an overdose, leading to ineffective treatment or potential toxicity.
Choice C rationale
Giving another dose is not safe because there is a risk of overdosing the infant. Digoxin toxicity can cause serious complications, and it is crucial to avoid administering more medication until the next scheduled dose.
Choice D rationale
Mixing the next dose with food is not appropriate because it does not address the immediate concern of potential overdose. The priority is to withhold the dose and monitor the infant's condition.
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