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. Assessing the child's pain level is important but may not be the first priority postoperatively, especially if there are signs of compromised circulation.

B. Rechecking the child's temperature is important but may not be the first priority postoperatively unless there are specific concerns related to temperature regulation.

C. Determining the child's sedation level is important for monitoring but may not be the first priority unless there are signs of respiratory compromise or other urgent concerns.

D. Comparing the child's pedal pulses is crucial in this situation as the child has undergone surgical procedures on the lower extremity, and changes in pedal pulses could indicate compromised circulation, which requires immediate attention to prevent complications such as compartment syndrome.

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Correct Answer is D

Explanation

A. Anti-nausea medication is not recommended unless prescribed by the provider and may mask symptoms of toxicity.

B. Increasing fluid intake is not a recommended response to vomiting from digoxin. Fluid balance should be monitored, but not specifically increased.

C. Mixing digoxin with formula is not advised because it can interfere with the absorption of the medication.

D. If an infant vomits after digoxin administration, the nurse should withhold the next dose and consult the provider before administering more. Vomiting may indicate digoxin toxicity, and giving the next dose without evaluation can be dangerous.

A. Verify if the toddler has an allergy to gelatin. B. Verify the route of administration for the vaccine. C. Inform the guardians that their toddler is too young to receive an influenza vaccine. D. Inform the guardians that their toddler will need two more doses of the vaccine within 6 months.

Correct Answer is A

Explanation

A. Verifying if the toddler has an allergy to gelatin is important because some vaccines, including the influenza vaccine, may contain gelatin as a stabilizer.

B. Verifying the route of administration is important but has already been specified (subcutaneous).

C. A toddler is an appropriate candidate for the influenza vaccine, and it is recommended annually.

D. A toddler typically receives one dose of the influenza vaccine unless it is the first time receiving it, in which case two doses are needed, but this is usually specified by the provider.

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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

Naxlex Comprehensive Predictor Exams

A nurse is caring for an infant who has heart failure and vomited following administration of digoxin. Which of the following actions should the nurse take?

Correct Answer is D

Explanation

A nurse is preparing to administer the influenza vaccine to a toddler. The prescription is written to administer the influenza vaccine subcutaneously. Which of the following actions should the nurse take?

Correct Answer is A

Explanation

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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.)