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 B
Explanation
A. "Bradycardia is an early indicator of a pneumothorax.": Bradycardia is not an early indicator of a pneumothorax. Common signs of pneumothorax in cystic fibrosis include sudden chest pain, difficulty breathing, and decreased breath sounds, not bradycardia.
B. "Administer a bronchodilator to the child after chest percussion therapy.": Chest percussion helps loosen secretions, and bronchodilators should be administered after the therapy to help open the airways and allow the mucus to be cleared more effectively.
C. "Engage the child in daily aerobic exercise.": While exercise is beneficial for children with cystic fibrosis, it should be tailored to the child's physical condition. Aerobic exercise might not be suitable for all children with CF, especially during exacerbations or respiratory distress.
D. "A pigeon-shaped chest might become evident as the disease progresses.": While a pigeon-shaped chest (pectus carinatum) can occur with CF due to chronic lung infections and hyperinflation, it is not the most immediate concern compared to respiratory therapy or infection control.
Correct Answer is D
Explanation
A. Keep the child home from school for at least 1 week: The child should stay home for at least 24 hours after starting antibiotics, not 1 week, to prevent spreading the infection.
B. Intramuscular injections will be required monthly: This is incorrect. Monthly intramuscular injections of penicillin are used for prophylaxis to prevent rheumatic fever, not for the treatment of acute group A β-hemolytic streptococcal infections.
C. Avoid the use of warm compresses around the head or neck: Warm compresses are not contraindicated for sore throats associated with group A strep infections unless there is an abscess or specific complication. This statement is not relevant.
D. Replace the child's toothbrush after 24 hours of taking antibiotics: The toothbrush should be replaced after 24 hours to prevent re-infection, as the child may still have bacteria in their mouth that can reintroduce the infection.
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