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 C
Explanation
Choice A reason: Evaluating the outcomes is not the first step in the evidence-based practice process, but the last one. The nurse should evaluate the outcomes after implementing the findings and comparing them with the expected results.
Choice B reason: Implementing the findings is not the first step in the evidence-based practice process, but the fourth one. The nurse should implement the findings after searching for evidence, appraising the quality and relevance of the evidence, and synthesizing the evidence.
Choice C reason: Formulating a question is the first step in the evidence-based practice process, as it helps to define the problem, the population, the intervention, the comparison, and the outcome. The nurse should formulate a question that is clear, specific, and answerable.
Choice D reason: Searching for evidence is not the first step in the evidence-based practice process, but the second one. The nurse should search for evidence after formulating a question, using appropriate sources, keywords, and strategies.
Correct Answer is D
Explanation
Choice A reason: Inflammation noted on the tissue edges of a client's wound is a finding that indicates wound infection, not wound healing. The nurse should monitor the wound for signs of infection, such as increased pain, swelling, warmth, odor, or purulent drainage.
Choice B reason: Increase in serosanguineous exudate from a client's wound is a finding that indicates wound deterioration, not wound healing. The nurse should assess the wound for signs of increased tissue damage, such as bleeding, necrosis, or sloughing.
Choice C reason: Erythema on the skin surrounding a client's wound is a finding that indicates wound irritation, not wound healing. The nurse should evaluate the wound for signs of inflammation, such as redness, heat, or tenderness.
Choice D reason: Deep red color on the center of a client's wound is a finding that indicates wound healing, as it shows the presence of granulation tissue. Granulation tissue is a sign of new tissue growth and blood vessel formation, which are essential for wound healing.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.