A nurse is caring for a 9-year old child on the pediatric unit
Complete the following sentence by using the lists of options.
The nurse should plan to
The Correct Answer is {"dropdown-group-1":"A","dropdown-group-2":"C"}
- Inspect the child’s oropharynx: After vomiting bright red blood, inspection can help confirm if bleeding is active in the throat. This assessment is key in identifying post-tonsillectomy hemorrhage.
- Obtaining a set of vital signs: Vital signs help evaluate the child’s hemodynamic stability, monitor for hypovolemic shock, and guide urgency for provider notification or surgical intervention.
Rationale for Incorrect Choices:
- Offer the child a red popsicle: Red-colored foods can mask signs of active bleeding. Also, offering oral intake during suspected hemorrhage is unsafe and may increase risk of aspiration.
- Place the child in a supine position: Supine positioning can increase aspiration risk if bleeding continues or worsens. The child should remain upright to protect the airway.
- Requesting a prescription for codeine: Codeine is not indicated in this situation and is contraindicated in children post-tonsillectomy due to risk of respiratory depression, especially during bleeding.
- Encouraging the child to cough and deep breathe: Coughing may dislodge clots and worsen bleeding. This action is inappropriate when bleeding is suspected in the oropharynx.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Liver function tests:Valproic acid is hepatotoxic and can lead to serious liver injury, especially in the early months of therapy. Baseline liver function tests (LFTs) are essential to assess hepatic status and establish a comparison point for future monitoring during treatment.
B. Potassium level:While important for general health, potassium is not directly affected by valproic acid. Valproic acid does not typically cause significant alterations in potassium, making this lab less relevant as a baseline before the first dose.
C. Uric acid level:Uric acid levels are more commonly associated with conditions like gout or medications like diuretics. Valproic acid does not impact uric acid metabolism, so this is not a priority lab for initiating therapy.
D. Thyroid function tests:Thyroid monitoring is more relevant for medications like lithium, which can cause hypothyroidism. Valproic acid does not typically interfere with thyroid function, so TSH or T4 levels are not necessary at baseline.
Correct Answer is A
Explanation
A. Abdominal distention: Paralytic ileus is a temporary cessation of bowel motility, often following surgery, especially abdominal or orthopedic procedures. Distention occurs due to accumulation of gas and fluid in the intestines and is a key indicator.
B. Oliguria: Reduced urine output may suggest dehydration or kidney issues but is not specific to paralytic ileus. It does not directly reflect gastrointestinal motility or function.
C. Dizziness: Dizziness can result from various causes like blood loss, medication, or orthostatic hypotension, but it is not a clinical sign of paralytic ileus and does not relate to bowel activity.
D. Watery stool: Watery or loose stools are more characteristic of diarrhea or bowel irritation. In paralytic ileus, bowel movement is typically absent, and stool passage is minimal or stopped.
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