A nurse is prioritizing potential complications that may occur to a pediatric client who has cellulitis. Which of the following is the primary concern?

Methicillin resistance

Redness in affected area

Risk for recurrence

Possible sepsis

Answer and Explanation

The Correct Answer is D

A. While methicillin resistance is a concern, it does not pose an immediate threat to the child’s life compared to the risk of sepsis.
B. Redness in the affected area is a typical symptom of cellulitis and, while it should be monitored, it is not the most urgent concern.
C. The risk for recurrence is important for long-term management but is not the primary concern in the acute phase of cellulitis.
D. Sepsis is the most immediate concern in cellulitis because the infection can rapidly spread into the bloodstream, leading to systemic infection and potential life-threatening complications.

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Correct Answer is ["A","C","G"]

Explanation

A. Administer morphine via IV bolus: Morphine is often used in infants with congenital heart defects, such as Tetralogy of Fallot, to reduce agitation, anxiety, and improve oxygenation by reducing systemic vascular resistance. However, this should be done cautiously, as it can decrease respiratory drive and should be administered per specific provider orders.

B. Prepare to assist with the insertion of a chest tube: A chest tube would not be indicated at this moment unless there is evidence of a pneumothorax, hemothorax, or pleural effusion. This scenario does not suggest these conditions.

C. Place the infant in a knee-chest position: This is a classic intervention for infants with Tetralogy of Fallot during a hypercyanotic spell. The knee-chest position increases systemic vascular resistance and reduces the right-to-left shunting of blood, helping to improve oxygenation and reduce cyanosis.

D. Request a prescription for a diuretic: Diuretics are commonly used in infants with congenital heart disease, including Tetralogy of Fallot, to manage fluid retention. This is important for controlling symptoms of heart failure, which may exacerbate cyanosis and respiratory distress.

E. Administer an additional dose of digoxin: While digoxin is used to manage heart failure in infants with congenital heart defects, there is no indication that the infant is in heart failure at this moment, and additional digoxin should only be administered with a provider's order, based on specific clinical needs.

F. Perform nasopharyngeal suctioning for a maximum of 5 seconds: Suctioning should only be performed if the infant is visibly obstructed or struggling with airway clearance. Prolonged or unnecessary suctioning could lead to further agitation and hypoxia in this infant.

G. Provide 100% oxygen by face mask: While oxygen alone isn't always fully effective in tet spells due to the shunting of blood, it's still an important intervention to maximize available oxygen.

A. Measure abdominal girth B. Notify practitioner C. Plan to move forward with procedure D. Auscultate for bowel sounds

Correct Answer is B

Explanation

A. Measuring abdominal girth is important in monitoring for abdominal distension, but the passing of a normal brown stool suggests that the intussusception may have resolved.

B. Passing a normal stool is a potential indication that the intussusception has spontaneously reduced, and the healthcare provider should be notified to reassess the plan of care.

C. Moving forward with the procedure may not be necessary if the intussusception has resolved, as indicated by the normal stool.

D. Auscultating for bowel sounds is important but would not be the primary action in this situation, as the passing of stool is a more immediate clue.

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A nurse is prioritizing potential complications that may occur to a pediatric client who has cellulitis. Which of the following is the primary concern?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is caring for an infant who has congenital heart disease. Which of the following actions should the nurse plan to take? Please select 3 actions. (Select all that apply.)

Correct Answer is ["A","C","G"]

Explanation

The nurse is caring for a boy with probable intussusception. While waiting for a radiologist-guided air enema to reduce the intussusception, he passes a normal brown stool. Which nursing action is the most appropriate?

Correct Answer is B

Explanation

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