A nurse is caring for a group of clients on a pediatric unit.
Which of the following clients is most at risk for insufficient vascular perfusion?
An adolescent who has a urinary tract infection.
A toddler who is receiving intravenous fluids.
A preschooler who has otitis media.
A school-age child who is in a spica cast.
The Correct Answer is D
The correct answer is D. A school-age child who is in a spica cast.
Choice A rationale
An adolescent with a urinary tract infection (UTI) is not at high risk for insufficient vascular perfusion. UTIs primarily affect the urinary system and do not typically impact vascular perfusion.
Choice B rationale
A toddler receiving intravenous fluids is not at high risk for insufficient vascular perfusion. IV fluids help maintain hydration and vascular volume, supporting adequate perfusion.
Choice C rationale
A preschooler with otitis media (ear infection) is not at high risk for insufficient vascular perfusion. Otitis media affects the middle ear and does not typically impact vascular perfusion.
Choice D rationale
A school-age child in a spica cast is at high risk for insufficient vascular perfusion. The cast can restrict blood flow, leading to complications such as compartment syndrome, which requires immediate medical attention.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
The correct answer is Choice C.
Choice A rationale
Checking the newborn’s eyes every 8 hours is not necessary for the management of hyperbilirubinemia or phototherapy. The primary concern during phototherapy is monitoring the newborn’s temperature and hydration status.
Choice B rationale
Placing mittens on the newborn’s hands is unrelated to the management of hyperbilirubinemia or phototherapy. Mittens are typically used to prevent the newborn from scratching themselves.
Choice C rationale
Monitoring the newborn’s temperature every 2 hours is essential during phototherapy because infants are at risk of hypothermia due to increased heat loss from the lights. This helps ensure the newborn maintains a stable body temperature.
Choice D rationale
Applying lotion to the newborn’s skin is not recommended during phototherapy as it can interfere with the effectiveness of the lights. The lotion can act as a barrier, reducing the amount of light that reaches the skin.
Correct Answer is A
Explanation
The correct answer is Choice A.
Choice A rationale
Continuous swallowing can be an indication of hemorrhage following a tonsillectomy and adenoidectomy. This is because the child may be swallowing blood that is coming from the surgical site.
Choice B rationale
Blood pressure of 95/56 mm Hg is within the normal range for a 5-year-old child and does not specifically indicate hemorrhage.
Choice C rationale
A heart rate of 54/min is lower than the normal range for a 5-year-old child and may indicate bradycardia, but it is not a specific sign of hemorrhage.
Choice D rationale
Flushing of the face is not a specific sign of hemorrhage. It may indicate other conditions but is not typically associated with bleeding following a tonsillectomy and adenoidectomy.
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