A pediatric nurse is caring for multiple clients and reviewing each of their care plans. Which of the following client care interventions requires revising?
Administer a bronchodilator two times a day for a child who has cystic fibrosis.
Check the neurovascular status every 4 hr of a child who had a hip spica cast placed 6 hr ago
Maintain eye shields for a newborn receiving phototherapy for hyperbilirubinemia.
Teach an adolescent who has an exacerbation of ulcerative colitis about a high-protein, low-fiber diet
The Correct Answer is D
Choice A reason: Administering a bronchodilator two times a day for a child who has cystic fibrosis is an appropriate intervention, as it helps to improve the child's respiratory function and prevent mucus accumulation.
Choice B reason: Checking the neurovascular status every 4 hr of a child who had a hip spica cast placed 6 hr ago is an appropriate intervention, as it helps to monitor the child's circulation and nerve function and detect any signs of compartment syndrome.
Choice C reason: Maintaining eye shields for a newborn receiving phototherapy for hyperbilirubinemia is an appropriate intervention, as it helps to protect the newborn's eyes from the harmful effects of the light and prevent eye damage.
Choice D reason: Teaching an adolescent who has an exacerbation of ulcerative colitis about a high-protein, low-fiber diet is an incorrect intervention, as it contradicts the dietary recommendations for this condition. A high-protein, low-fiber diet can worsen the inflammation and symptoms of ulcerative colitis. The nurse should teach the adolescent about a low-residue, high-calorie, high-protein diet instead.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A reason: A client who reports shortness of breath and left neck and shoulder pain may have a cardiac problem, which is a serious condition. However, this client is not the highest priority, as the symptoms are not life-threatening at the moment.
Choice B reason: A client who has active bleeding from a puncture wound of the left groin area is the highest priority, as this client is at risk of hemorrhage, shock, and infection. The nurse should apply direct pressure to the wound, elevate the leg, and monitor the vital signs.
Choice C reason: A client who has a raised red skin rash on his arms, neck, and face may have an allergic reaction, which is a potential emergency. However, this client is not the highest priority, as the symptoms are not severe enough to indicate anaphylaxis.
Choice D reason: A client who reports right-sided flank pain and is diaphoretic may have a kidney stone, which is a painful condition. However, this client is not the highest priority, as the symptoms are not life-threatening unless there is an obstruction or infection.
Correct Answer is A
Explanation
Choice A reason: Returning unused supplies from the bedside to the unit's supply stock is an appropriate action to include in the cost-containment plan. This action prevents waste and saves money by reusing the supplies that are not contaminated or expired.
Choice B reason: Using clean gloves rather than sterile gloves for colostomy care is not an appropriate action to include in the cost-containment plan. This action compromises the quality and safety of care by increasing the risk of infection and cross-contamination. Sterile gloves are required for colostomy care to prevent introducing microorganisms into the stoma or the pouch.
Choice C reason: Storing opened bottles of normal saline in a refrigerator for up to 48 hours is not an appropriate action to include in the cost-containment plan. This action violates the infection control and medication administration policies. Opened bottles of normal saline should be discarded after 24 hours or after a single use, depending on the facility's protocol. Refrigerating the bottles does not extend their shelf life or sterility.
Choice D reason: Waiting to dispose of sharps containers until they are completely full is not an appropriate action to include in the cost-containment plan. This action poses a hazard and a liability for the staff and the clients. Sharps containers should be disposed of when they are three-quarters full or according to the manufacturer's instructions. Overfilling the containers can cause needlestick injuries or spillage of contaminated materials.
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