Which intervention should be implemented for a school-age client admitted to the pediatric intensive care unit (PICU) in critical condition after a motor vehicle accident?

Keep alarm levels low.

Keep the lights dimmed at night.

Encourage the same nurses to take care of the patient on consecutive days.

Facilitate visits from school friends.

Answer and Explanation

The Correct Answer is C

Choice A reason: Keeping alarm levels low is important to reduce stress and promote a healing environment, but it is not the most impactful intervention for personalized care.

Choice B reason: Dimming the lights at night helps maintain a normal sleep-wake cycle, which is beneficial but not as specific to the client's individual needs as continuity of care.

Choice C reason: Having the same nurses care for the patient on consecutive days can provide consistency and build trust, which is especially important for a child in critical condition.

Choice D reason: While visits from school friends can be uplifting, they may not be feasible or appropriate for a client in critical condition in the PICU. The priority is ensuring stable and consistent care.

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Correct Answer is C

Explanation

Choice A reason: Placing the infant flat and prone is not the first priority in the care of an infant with gastroschisis.
Choice B reason: While providing warmth and promoting bonding are important, they are not the immediate priority upon admission for an infant with gastroschisis.
Choice C reason: This is the correct choice. The exposed abdominal organs in gastroschisis must be protected immediately to prevent heat and fluid loss and to reduce the risk of infection.
Choice D reason: Breastfeeding is important for bonding and nutrition but is not the first intervention for an infant with gastroschisis.

A. Give the client six ounces of non-diet carbonated soda and instruct the client to drink it entirely. B. Document the glucose reading in the electronic medical record as the only action needed. C. Collect a blood specimen by venipuncture to send to the laboratory for serum glucose analysis. D. Prepare the prescribed dose of rapid-acting insulin from the sliding scale instructions.

Correct Answer is A

Explanation

Choice A reason: This is the correct choice. A blood glucose level of 56 mg/dL indicates hypoglycemia, and the immediate priority is to raise the blood sugar level. Non-diet carbonated soda can provide a quick source of sugar.
Choice B reason: Documenting the reading is important but does not address the immediate need to correct the low blood sugar.
Choice C reason: While confirming the reading with a laboratory test is a good practice, it is not the first action to take when dealing with hypoglycemia.
Choice D reason: Administering insulin would be contraindicated as it would lower the blood sugar even further.

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Which intervention should be implemented for a school-age client admitted to the pediatric intensive care unit (PICU) in critical condition after a motor vehicle accident?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

An infant has been admitted to the Neonatal Intensive Care Unit (NICU) with congenital gastroschisis. Which intervention should the nurse perform first upon admission to the unit?

Correct Answer is C

Explanation

The nurse obtains a fingerstick blood glucose level using bedside lancet/glucose meter equipment from a client with a prescribed sliding scale insulin protocol. The meter indicates 56 mg/dL (3.12 mmol/L). At this time, which intervention should the nurse implement first?

Correct Answer is A

Explanation

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