Exhibits

A nurse is caring for a child who is 2 hr postoperative. Which of the following actions should the nurse take first? (Click the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

Assess the child's pain level.

Recheck the child's temperature.

Determine the child's sedation level.

Compare the child's pedal pulses.

Answer and Explanation

The Correct Answer is D

A.   While assessing pain level is important, ensuring adequate perfusion and circulation takes precedence.
B.   Rechecking the child's temperature may be necessary but is not as immediately critical as assessing pedal pulses.
C.   Determining the child's sedation level is important for monitoring postoperative status but is not the priority at this time.
D.   Assessing the child's pedal pulses is crucial following a motor-vehicle crash and surgical procedures involving the lower extremities. It helps to evaluate the perfusion and circulation to the extremities, especially after a leg open reduction and fixation surgery.

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Correct Answer is D

Explanation

A. Visual acuity should be assessed for each eye separately first, then both eyes together to detect any differences between the eyes.
B. The nurse should position the child 3 meters (10 feet) from the chart and ask the child to point in the direction of the open end of each letter.
C. If the child wears glasses, they should be tested with and without their glasses to assess visual acuity accurately.
D. A tumbling E chart, where the child identifies the direction of the E (up, down, left, or right), is commonly used for assessing visual acuity in young children who may not yet know letters.

A. "I will ensure that my child is tested for tuberculosis every year." B. "The risk of transmission decreases once my child is on zidovudine for 2 weeks." C. "My child will need to double his medications for the next 6 months." D. "My child will need to repeat his childhood immunizations once he is in remission."

Correct Answer is A

Explanation

A. A child with HIV is at increased risk of developing tuberculosis and should be screened annually.
B. This is incorrect because the risk of transmission does not depend on the duration of zidovudine therapy, but on the viral load and the exposure to body fluids.
C. Doubling medications is not a standard practice in HIV management and may lead to medication errors or adverse effects.
D. Childhood immunizations are important for children with HIV, but they may need to be adjusted based on the child's immune status and treatment regimen, not just during remission.

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Exhibits A nurse is caring for a child who is 2 hr postoperative. Which of the following actions should the nurse take first? (Click the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)

Nursing Test Bank

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Correct Answer is A

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Exhibits

A nurse is caring for a child who is 2 hr postoperative. Which of the following actions should the nurse take first? (Click the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.)