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 B
Explanation
Minimize crying.
Choice A rationale:
Encouraging attachment might be important for the child's emotional well-being, but in the immediate postoperative period after cleft lip repair, minimizing crying takes priority. Crying can place stress on the suture line and disrupt the healing process.
Choice B rationale:
Minimizing crying is crucial to prevent tension on the suture line and ensure proper healing of the cleft lip repair. Excessive crying can lead to increased pressure on the surgical site and potential complications. Elbow restraints are applied to prevent the child from touching the surgical site, so minimizing crying helps to maintain the effectiveness of these restraints.
Choice C rationale:
Restricting oral intake is not a priority in this case. While it's important to ensure the child doesn't consume anything that might harm the surgical site, it's not the highest priority action compared to preventing tension on the suture line.
Choice D rationale:
Initiating range of motion is not the priority postoperative intervention for a cleft lip repair. The primary concern at this stage is to prevent disruption of the surgical site and ensure proper healing, making minimizing crying a higher priority.
Correct Answer is C
Explanation
Choice A rationale:
Placing the infant on her left side with a pillow supporting her back after feeding is appropriate as it prevents aspiration and reflux due to gravity.
Choice B rationale:
Covering the cast with a towel to prevent accidental soiling is a sensible action, ensuring the cast remains clean and dry.
Choice C rationale:
The mother using the football hold to position the infant securely to one side might hinder the cast's stability and could potentially cause discomfort or displacement.
Choice D rationale:
Supporting both the infant's head and cast when leaning her forward for burping is essential to maintain the cast's integrity and to prevent strain on the infant's body.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today
Report Wrong Answer on the Current Question
Do you disagree with the answer? If yes, what is your expected answer? Explain.
Kindly be descriptive with the issue you are facing.