Which client on an acute care pediatric unit requires the nurse’s immediate attention?
An 18-month-old client who had a cleft palate repair and is crying in pain.
A 12-year-old client who had an appendectomy and refuses to ambulate.
An 8-year-old client who had a tonsillectomy and is swallowing frequently.
A 15-year-old client who has an IV infusion and reports pain at the insertion site.
The Correct Answer is C
Choice A rationale
While pain management is important following a cleft palate repair, it does not typically require immediate attention. Pain can be managed with appropriate analgesics and does not typically present an immediate risk to the patient’s health.
Choice B rationale
A patient refusing to ambulate following an appendectomy does not typically require immediate attention. Encouraging mobility is important for recovery, but refusal to ambulate does not present an immediate risk to the patient’s health.
Choice C rationale
Frequent swallowing following a tonsillectomy could indicate post-operative bleeding, which requires immediate attention. Post-tonsillectomy hemorrhage can be a life-threatening condition that requires immediate intervention.
Choice D rationale
While pain at the site of an IV infusion should be addressed, it does not typically require immediate attention unless there are signs of infection or infiltration. It does not present an immediate risk to the patient’s health.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is B
Explanation
Choice A rationale:
Abdominal rigidity and pain on palpation are not typical signs of pyloric stenosis. Pyloric stenosis usually presents with non-bilious projectile vomiting, a palpable olive-shaped mass in the upper abdomen, and signs of dehydration.
Choice B rationale:
A rounded abdomen and hypoactive bowel sounds are characteristic signs of pyloric stenosis. The hypertrophied pyloric muscle obstructs the passage of food from the stomach to the duodenum, leading to gastric distention, visible peristalsis, and vomiting. The infant may appear hungry after vomiting and will continue to feed, leading to weight loss.
Choice C rationale:
Visible peristalsis and weight loss are consistent with pyloric stenosis. The visible peristalsis occurs as the infant tries to force the stomach contents through the narrowed pyloric sphincter. Weight loss is a result of poor feeding and vomiting.
Choice D rationale:
Distention of the lower abdomen and constipation are not typical findings in pyloric stenosis. Constipation suggests a lower gastrointestinal issue, while pyloric stenosis primarily affects the upper gastrointestinal tract.
Correct Answer is A
Explanation
Choice A rationale
Activated charcoal is often used in the management of poisoning. It works by binding to the poison in the stomach and preventing it from being absorbed into the body14.
Choice B rationale
Osmotic diarrheal agents are not typically used in gastric lavage. These agents work by increasing the amount of water in the intestinal tract, which can stimulate bowel movements14.
Choice C rationale
Syrup of ipecac was once used to induce vomiting in cases of poisoning, but it is no longer recommended for use in poisoning cases14.
Choice D rationale
0.9% sodium chloride, or normal saline, is a type of fluid that’s often used in medical treatments, but it’s not typically used in gastric lavage for poisoning14.
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