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. Lack of adequate ventricle strength to pump blood to the body: While right ventricular hypertrophy is part of Tetralogy of Fallot, the primary cause of fatigue is inadequate oxygenation, not muscle strength.
B. Restricted blood flow leaving the heart: This contributes to low oxygen levels but isn’t the direct reason for fatigue; the issue lies in oxygen availability for metabolism.
C. Inadequate oxygenation for supporting energy metabolism: The structural defects cause reduced oxygen delivery to tissues, leading to fatigue during activities like feeding.
D. Increased circulation pressure to the lungs: Pulmonary stenosis reduces blood flow to the lungs, but this doesn’t directly explain fatigue from eating.
Correct Answer is B
Explanation
A. Methylprednisolone: Methylprednisolone is a corticosteroid used to reduce inflammation but is not the first-line treatment for an acute asthma attack. It is used in the management of longer-term control and inflammation after the initial symptoms are managed.
B. Albuterol: Albuterol is a short-acting beta-agonist (SABA) that provides quick relief by dilating the airways. It is the first medication given during an acute asthma attack to relieve bronchospasm and improve airflow.
C. Montelukast: Montelukast is a leukotriene receptor antagonist used for long-term control and prevention of asthma symptoms but is not used in an acute asthma attack.
D. Fluticasone: Fluticasone is an inhaled corticosteroid used for long-term management of asthma to reduce inflammation, but it is not effective in treating an acute asthma attack.
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