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 D
Explanation
Choice A reason: Respecting the client's decision and informing the provider is an appropriate action, but not the first one that the nurse should take. The nurse should first assess the client's understanding of the condition and the treatment options, and provide education and support as needed.
Choice B reason: Explaining the benefits and risks of the procedure is an appropriate action, but not the first one that the nurse should take. The nurse should first assess the client's understanding of the condition and the treatment options, and provide education and support as needed.
Choice C reason: Suggesting alternative treatments for the condition is an appropriate action, but not the first one that the nurse should take. The nurse should first assess the client's understanding of the condition and the treatment options, and provide education and support as needed.
Choice D reason: Assessing the client's understanding of the consequences of uterine prolapse and the need for surgery is the first and most appropriate action that the nurse should take. The nurse should determine the client's knowledge, beliefs, and preferences regarding the condition and the surgery, and address any gaps, misconceptions, or concerns. The nurse should also respect the client's autonomy and right to make informed decisions about their health care.
Correct Answer is C
Explanation
Choice A reason: A respiratory therapist is a health care professional who can provide education and assistance on the use and maintenance of the nebulizer, but not on the financial aspects of obtaining it. The nurse should collaborate with the respiratory therapist to ensure the parent understands how to administer the nebulized medications to the child.
Choice B reason: A pharmacist is a health care professional who can provide information and advice on the medications prescribed for the child, but not on the financial aspects of obtaining the nebulizer. The nurse should consult with the pharmacist to ensure the parent knows how to store and handle the medications safely.
Choice C reason: A social worker is a health care professional who can provide support and resources to the parent regarding the financial aspects of obtaining the nebulizer. The nurse should refer the parent to the social worker to explore options such as insurance coverage, payment plans, or assistance programs.
Choice D reason: Child protective services is an agency that investigates and intervenes in cases of child abuse or neglect. The nurse should not refer the parent to child protective services, as this could imply that the parent is intentionally harming or neglecting the child, which is not the case. The nurse should respect the parent's rights and dignity, and offer help and guidance.
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