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.
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.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is C
Explanation
Rationale:
A. Visual analog scales rely on the child's ability to comprehend and interpret visual cues, which may be challenging for a cognitively impaired toddler.
B. FACES scales require the child to identify their pain level based on facial expressions, which may also be challenging for a cognitively impaired toddler.
C. FLACC (Face, Legs, Activity, Cry, Consolability) scales are specifically designed for non-verbal or cognitively impaired individuals, assessing pain based on observable behaviors such as facial expression, leg movement, activity level, cry, and ability to be consoled.
D. CRIES scales are primarily used for assessing pain in newborns and infants and may not be as applicable for a cognitively impaired toddler.
Correct Answer is C
Explanation
A. Holding urine for extended periods may indicate urinary retention, which is not the desired outcome of treatment for enuresis.
B. Drinking less may not necessarily indicate treatment effectiveness and could lead to dehydration.
C. Waking to urinate in response to the alarm indicates improved bladder control and responsiveness to conditioning therapy for enuresis.
D. Kegel exercises primarily target pelvic floor muscles and may not directly address the underlying causes of enuresis.
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