A nurse is caring for a child who is 2 hr postoperative.
Which of the following actions should the nurse take first? (Click the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)
Compare the child's pedal pulses.
Determine the child's sedation level.
Assess the child's pain level.
Recheck the child's temperature.
Correct Answer : A
Given the child's recent motor vehicle accident and subsequent orthopedic surgeries, assessing the peripheral circulation is crucial. Comparing pedal pulses helps to determine the adequacy of blood flow to the lower extremities and identify any potential complications such as compartment syndrome. This assessment should be prioritized immediately.
While assessing pain, sedation level, and rechecking temperature are all important, they do not take precedence over assessing the child's circulation and perfusion status following major orthopedic surgeries.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Shakiness is a common symptom of hypoglycemia. When blood glucose levels drop, the body may react with symptoms like trembling or shaking. This is because low blood sugar levels can trigger the release of adrenaline, leading to physical symptoms such as shakiness.
B. While decreased appetite can occur in various conditions, it is not a primary or specific manifestation of hypoglycemia. Typically, hypoglycemia causes symptoms related to the body’s response to low glucose levels, such as shakiness, sweating, or confusion, rather than a decrease in appetite.
C. Thirst is more commonly associated with hyperglycemia (high blood glucose levels), not hypoglycemia. When blood glucose levels are high, the body tries to get rid of the excess sugar through increased urination, leading to dehydration and increased thirst. This is not a typical sign of low blood sugar.
D. Increased capillary refill time is generally a sign of poor perfusion or dehydration and is not specific to hypoglycemia. In hypoglycemia, the capillary refill time is usually normal, though other signs such as shakiness, sweating, or irritability are more indicative of low blood sugar levels.
Correct Answer is C
Explanation
A. Aspirin should never be given to children with varicella due to the risk of Reye's syndrome, a serious and potentially fatal condition.
B. A warm blanket can increase the child's body temperature and discomfort. Cool compresses or baths are often recommended to relieve itching.
C. Varicella is a highly contagious airborne disease. Isolation precautions, including airborne precautions, are essential to prevent the spread of the virus.
D. Koplik spots are associated with measles, not varicella.
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