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. Pulmonary function test: While useful in assessing lung function, this test is not definitive for diagnosing cystic fibrosis.
B. Sputum culture: This can help identify respiratory infections, but it is not used for diagnosing cystic fibrosis.
C. Sweat chloride test: The sweat chloride test is the most definitive diagnostic test for cystic fibrosis. Elevated chloride levels in the sweat are indicative of the disease.
D. Stool fat content analysis: This test can be helpful in identifying malabsorption issues but is not definitive for cystic fibrosis diagnosis.
Correct Answer is ["C","D","G"]
Explanation
- A. Provide oxygen at 6 L/min via nasal cannula: Oxygen is only used if the patient has hypoxemia (O2 saturation below 92%), which is not indicated in this scenario.
B. Perform passive ROM exercises: Not appropriate during a sickle cell crisis due to the risk of exacerbating pain.
C. Administer IV fluids: Essential to reduce blood viscosity and prevent further sickling.
D. Obtain consent for a blood transfusion: Necessary in severe anemia (e.g., hemoglobin of 5 g/dL).
E. Restrict fluid intake to 1,400 mL/day: Fluid restriction is contraindicated; hydration is key to management.
F. Administer meperidine IV: Meperidine is generally avoided due to the risk of neurotoxicity; other opioids (e.g., morphine) are preferred.
G. Encourage bedrest: Reduces oxygen demand during a crisis.
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