A nurse is working with several clients on an acute care pediatric unit. Which of the following clients requires the nurse's immediate attention?
A 12-year-old client who had an appendectomy and refuses to ambulate
An 18-month-old client who had a cleft palate repair and is crying in pain
An 8-year-old client who had a tonsillectomy and is swallowing frequently
A 15-year-old client who has an IV infusion and reports pain at the insertion site
The Correct Answer is C
A. A 12-year-old client who had an appendectomy and refuses to ambulate: Refusal to ambulate post-appendectomy may be concerning for complications like constipation or post-operative discomfort, but it is not an immediate emergency unless accompanied by other signs of complications like infection or bleeding.
B. An 18-month-old client who had a cleft palate repair and is crying in pain: Pain is expected following surgery, and while it should be addressed promptly, it does not constitute an immediate emergency unless there are signs of distress or complications.
C. An 8-year-old client who had a tonsillectomy and is swallowing frequently: Frequent swallowing after a tonsillectomy can indicate bleeding, which is a potential complication requiring immediate attention. It is important to assess for signs of bleeding, such as increased swallowing or a change in respiratory status.
D. A 15-year-old client who has an IV infusion and reports pain at the insertion site: Pain at the IV insertion site could indicate a complication like infiltration or phlebitis, but it is not an immediate emergency unless associated with other severe symptoms (e.g., swelling or systemic infection).
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
A. Inhaled Glucocorticoid: Used for managing asthma or other respiratory conditions, not for cardiac function.
B. Beta Adrenergic Blocker: Reduces blood pressure and heart rate but is not the mechanism of Digoxin.
C. Cardiac Glycoside: Digoxin is used to improve myocardial contractility and slow the heart rate, which aligns with this classification.
D. Angiotensin Enzyme Inhibitor: Typically used to manage hypertension and heart failure by affecting the renin-angiotensin system.
Correct Answer is C
Explanation
A. Inhaled steroid: Inhaled corticosteroids are used for long-term control of asthma and are not typically used during an acute asthma attack. They work by reducing inflammation, but they do not provide immediate relief of bronchoconstriction.
B. Oral leukotriene modifiers: Leukotriene modifiers are used for long-term asthma management, but they are not effective in providing quick relief during an acute asthma attack.
C. Inhaled beta agonist: Beta agonists (e.g., albuterol) are the first-line treatment for quick relief during an asthma attack. They work by relaxing the muscles around the airways to improve airflow and relieve symptoms like chest tightness and coughing.
D. Oral steroids: Oral steroids (e.g., prednisone) are used for severe asthma exacerbations, but they are not used as the first-line treatment for quick relief of symptoms like tight chest and cough. They take time to reduce inflammation.
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