The nurse is caring for a 2-year-old patient. Which observation requires immediate action by the nurse?
The identification band has fallen off the patient's leg.
The IV fluid is 48 hours old.
The crib rails are halfway up.
The bed linen is damp.
The Correct Answer is B
Choice A rationale:
The identification band falling off the patient's leg is a documentation concern and doesn't require immediate action unless the patient is at risk of wandering or abduction.
Choice B rationale:
IV fluids should be changed every 24 hours to prevent bacterial growth and infection. Using fluids that are 48 hours old increases the risk of introducing infection to the patient.
Choice C rationale:
The crib rails being halfway up is not an immediate concern unless the child is at risk of falling or climbing out of the crib.
Choice D rationale:
Damp bed linen can be addressed during the next bedding change. It may not require immediate action unless the patient's skin integrity is at risk.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is D
Explanation
Choice D rationale:
Preschool-aged children may fear pain and bleeding, and applying a small dressing after venipuncture helps alleviate anxiety. It provides a sense of control and comfort, as the child perceives their active participation in caring for the site.
Choice A rationale:
Showing the needle and syringe might intensify anxiety in the child, making venipuncture more distressing. It's important to minimize any distress during the procedure.
Choice B rationale:
Allowing the child to help cleanse the site could lead to more anxiety as the child might interpret it as their own responsibility for the procedure.
Choice C rationale:
Encouraging the child to show the site to adults may not be reassuring for the child and could potentially exacerbate their apprehension.
Correct Answer is ["A","B","C"]
Explanation
Choice A rationale:
Ribbon-like stools are a classic sign of Hirschsprung's disease, indicating narrowed or obstructed bowel segments due to the absence of ganglion cells in the intestine's muscular layers.
Choice B rationale:
A distended abdomen is common in Hirschsprung's disease due to the accumulation of stool and gas in the narrowed segments of the intestine.
Choice C rationale:
Chronic constipation is a result of the dysfunctional intestinal motility caused by Hirschsprung's disease. The absence of ganglion cells leads to a lack of peristalsis and difficulty passing stools.
Choice D rationale:
Black and tarry stools are indicative of upper gastrointestinal bleeding, often caused by conditions like peptic ulcers. This finding is not directly related to Hirschsprung's disease.
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