A nurse is discussing post-procedure interventions with new pediatric nurses. Which statement addresses the most immediate safety action required?
“Remove all equipment related to the procedure from the child’s environment.”
“Handle all contaminated linens in accordance with the facility policies.”
“Assess to ensure that the side rails are up and the bed is lowered to the floor.”
“Document the procedure and the response of the child as soon as the procedure is completed.”
The Correct Answer is C
Choice A reason: Removing equipment reduces clutter but is less urgent than preventing falls, especially post-procedure when a child may be disoriented. Ensuring side rails and a low bed prioritizes safety, making this secondary and incorrect for the most immediate action in pediatric post-procedure care.
Choice B reason: Handling contaminated linens follows infection control but is not the immediate safety concern post-procedure. Preventing falls with side rails and a low bed is critical, making this less urgent and incorrect compared to the priority of ensuring the child’s physical safety after the procedure.
Choice C reason: Assessing side rails up and bed lowered prevents falls, the most immediate safety risk post-procedure when a child may be sedated or unsteady. This aligns with pediatric safety protocols, making it the correct statement for the most urgent action in post-procedure interventions.
Choice D reason: Documentation is essential but not immediate compared to fall prevention, which protects the child post-procedure. Side rails and bed positioning take precedence, making this subsequent and incorrect for the most urgent safety action required after a pediatric procedure in the hospital.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is ["A","D","E"]
Explanation
Choice A reason: Normal heart rate and respirations indicate reduced physiological stress from pain, supporting effective medication in a terminally ill child. This aligns with pediatric pain assessment criteria, making it a correct assessment to document as evidence of successful pain relief post-medication administration.
Choice B reason: Withdrawing from the environment suggests ongoing distress or pain, not relief. Normal vitals and low pain scores indicate effectiveness, making this incorrect, as it reflects a negative outcome rather than supporting successful pain management in the terminally ill child’s evaluation.
Choice C reason: A flexed position may indicate persistent pain or discomfort, not relief. Sleeping or low pain scores better demonstrate effectiveness, making this incorrect, as it does not support the medication’s success in alleviating pain in the terminally ill client during the assessment.
Choice D reason: Verbalizing a 1 on the pain scale directly indicates minimal pain, confirming the medication’s effectiveness in a terminally ill child. This aligns with pediatric pain management standards, making it a correct assessment to document as evidence of successful pain relief post-administration.
Choice E reason: Quietly sleeping on the parent’s lap suggests comfort and pain relief, a positive sign in a terminally ill child. This aligns with behavioral pain assessment in pediatrics, making it a correct observation to document as evidence of effective medication for pain management.
Correct Answer is A
Explanation
Choice A reason: A complete fracture occurs when bone fragments are fully separated, disrupting the bone’s continuity. This aligns with orthopedic definitions, as separation indicates a break through the entire bone, requiring intervention. The nurse’s explanation matches this, making it the correct term for separated fracture fragments in children, consistent with pediatric trauma care.
Choice B reason: An incomplete fracture involves a partial break, with fragments not fully separated, common in children’s flexible bones. The question specifies separated fragments, which does not fit this definition. This choice is incorrect, as it contradicts the description of a complete separation of bone fragments in the context of fracture classification.
Choice C reason: A spiral fracture is caused by twisting, with a helical break pattern, but separation of fragments is not its defining feature. Complete fractures specifically describe separated fragments, making this incorrect, as spiral refers to shape, not the extent of fragment separation in fractures, per orthopedic terminology.
Choice D reason: A greenstick fracture is an incomplete break where one side bends and the other cracks, typical in children. Separated fragments indicate a complete fracture, not a greenstick, making this incorrect, as greenstick fractures do not involve full separation of bone fragments as described in the nurse’s explanation.
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