An 18-month-old child has just returned from the operating room with intravenous solution running into a vein in the right hand, a nasogastric tube in place, and a dressing covering the abdomen. Which of the following actions by the nurse would be appropriate? Select all that apply

Administer an NSAID per the health-care provider’s orders.

Place an intake and output sheet at the child’s bedside.

Request an order for an elbow restraint for the child’s left arm.

Assess the child’s pain level using an age appropriate pain rating scale.

Compare the intravenous solution to the health-care provider’s orders.

Answer and Explanation

Correct Answer : B,C,D,E

Postoperative care for toddlers requires close monitoring of safety, fluid balance, pain control, and equipment management. Since 18-month-old children are active and curious, they may try to pull at tubes or IV lines, so nurses must anticipate needs and prevent complications.

Rationale for correct answers:

B. Accurate I&O monitoring is essential for a post-op child with IV fluids and an NG tube to assess hydration, kidney function, and fluid balance.

C. An elbow restraint prevents the child from pulling out the NG tube or IV line or interfering with the abdominal dressing. Always requires a provider’s order. A nurse cannot apply it independently.

D. At 18 months, the child cannot use a numeric scale. The nurse should use a validated tool such as the FLACC (Face, Legs, Activity, Cry, Consolability) scale to assess pain.

E. Safe practice requires verification of IV solution and rate against the provider’s orders before continuing infusion. This prevents medication or fluid errors.

Rationale for incorrect answers:

A. NSAIDs are not typically first-line in immediate post-op care for an 18-month-old with abdominal surgery due to risk of bleeding and gastric irritation. Stronger analgesics (opioids, acetaminophen IV/PO) are often ordered instead.

Take home points

Post-op care for toddlers focuses on safety (verify orders), comfort (age-appropriate pain assessment), and monitoring (I&O, vital signs, wound care).
Pain assessment tools must be developmentally appropriate (e.g., FLACC scale for infants and toddlers).
NSAIDs are not routine post-op measures and require careful consideration of risks and alternatives.
Nurses should always double-check IV solutions against provider orders to prevent errors.

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Free Nursing Study Resources

Correct Answer is ["A","B","C","D"]

Explanation

Adolescents recovering from surgery face not only physical healing but also psychological and social challenges. The nurse must focus on clinical and developmental priorities such as pain management, wound healing, and psychosocial support, such as peer connections.

Rationale for correct answers:

A. Teen’s pain level is always a priority in postoperative care. Even if the adolescent appears engaged in TV or games, pain may still be present. Self-report remains the gold standard for pain assessment.

B. Socialization is very important for adolescents. According to Erikson’s psychosocial stage (identity vs. role confusion), peer support directly affects self-esteem and coping during hospitalization.

C. Level of healing of the teen’s surgical site is essential to evaluate wound healing, risk of infection, and overall recovery progress after reconstructive surgery.

D. Academic progress should be included in a holistic nursing assessment of adolescents. School work provides normalcy, supports developmental tasks, and helps maintain a sense of routine and achievement. It is part of psychosocial well-being, not just physical health.

Rationale for incorrect answer:

E. How well the teen is performing on the video games is not a relevant measure of health or recovery. Games are simply a distraction tool and a coping mechanism.

Take home points

Nursing care for adolescents must be holistic:
- Physical including pain and wound healing
- Emotional/Social including peer and family support
- Developmental/Academic including school progress, independence
Maintaining normal routines such as schoolwork helps adolescents cope with hospitalization and prepares them for reintegration post-discharge.
Distractions like games are useful coping tools but are not indicators of well-being.

A. Delay the dressing change until the child is finished playing in the playroom. B. Perform the dressing change in the playroom while the child finishes drawing the picture. C. Escort the child to the treatment room for the dressing change and back to the playroom once it is done. D. Ask the child whether the dressing change should be performed at that time or after the child has finished the drawing.

Correct Answer is C

Explanation

Pain is a complex sensory and emotional experience that signals actual or potential harm to the body. Pain can exist without visible injury. It’s influenced by past experiences, emotions, and environment. It is subjective hence only the person experiencing it can truly describe its intensity and impact.

Rationale for correct answer:

C. Painful or stressful procedures should not be performed in the child’s playroom or hospital bed. The playroom should remain a safe, positive environment for coping and distraction. Performing the procedure in a designated treatment room preserves the child’s sense of security and allows the playroom to remain associated with fun and comfort. Escorting the child back afterward helps re-establish normalcy and security.

Rationale for incorrect answers:

A. Delaying procedures unnecessarily can interfere with treatment schedules and may prolong anxiety.

B. Performing the dressing change in the playroom while the child finishes drawing the picture is inappropriate. The playroom must remain a safe space for positive experiences; painful procedures should never be done there.

D. Offering choices is good in pediatric care, but in this case the timing of the dressing change is a medical necessity. Giving the child this option may create false expectations or resistance.

Take home points

Never perform painful procedures in a child’s playroom or hospital bed, these spaces should be safe, comforting zones.
Use a treatment room for procedures to help children cope better with hospitalization.
Escorting the child back to play afterward helps restore a sense of normalcy and reduces trauma.
Offer choices only when appropriate (e.g., which arm for a blood pressure cuff), but not when the procedure’s timing is medically necessary.

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An 18-month-old child has just returned from the operating room with intravenous solution running into a vein in the right hand, a nasogastric tube in place, and a dressing covering the abdomen. Which of the following actions by the nurse would be appropriate? Select all that apply

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

Correct Answer is ["A","B","C","D"]

Explanation

An 8-year-old child is in the playroom drawing a picture. The child’s painful dressing change is due to be performed. Which of the following actions by the nurse is appropriate?

Correct Answer is C

Explanation

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