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Which client on an acute care pediatric unit requires the nurse's immediate attention?
- A. An 18-month-old client who had a cleft palate repair and is crying in pain.
- B. A 12-year-old client who had an appendectomy and refuses to ambulate.
- C. An 8-year-old client who had a tonsillectomy and is swallowing frequently.
- D. A 15-year-old client who has an IV infusion and reports pain at the insertion site.
Correct Answer: C
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. 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. 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. 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.
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A nurse at a pediatrician's office answers a phone call from a parent whose child just ingested 15 vitamin tablets with added ferrous sulfate. Which of the following instructions should the nurse give to the parent?
- A. Administer syrup of ipecac.
- B. Give the child 120 mL (8 oz) of orange juice.
- C. Contact the poison control center.
- D. Provide the child with a high-carbohydrate snack.
Correct Answer: C
Rationale: Administering syrup of ipecac is not recommended in cases of iron overdose. Ipecac was once used to induce vomiting in cases of poisoning, but it is no longer recommended due to potential complications and lack of evidence for effectiveness. Giving the child orange juice will not help in this situation. While vitamin C can enhance iron absorption, it does not have an effect on iron that has already been absorbed into the body. Contacting the poison control center is the appropriate action. They can provide immediate advice on what to do in cases of potential iron overdose. Providing a high-carbohydrate snack will not help in this situation. It will not affect the absorption or toxicity of the iron.
A nurse is caring for an adolescent following the application of a plaster cast for a fractured right tibia. Which of the following actions should the nurse take?
- A. Discourage the client from ambulating.
- B. Use a hair dryer on a hot setting to dry the cast.
- C. Keep the client's leg in a dependent position.
- D. Perform a neurovascular check of the lower extremities.
Correct Answer: D
Rationale: Discouraging the client from ambulating is not the best action. While it's important to limit weight-bearing activities initially, movement is encouraged to promote circulation and prevent complications such as deep vein thrombosis. Using a hair dryer on a hot setting to dry the cast is not recommended. Heat can cause the cast to dry out and crack, and it can also burn the skin. Keeping the client's leg in a dependent position is not advisable. This can lead to increased swelling and pain, and potentially delay healing. Performing a neurovascular check of the lower extremities is the correct action. This involves assessing for pain, pallor, pulselessness, paresthesia, and paralysis. These checks are crucial for monitoring for complications such as compartment syndrome and ensuring the cast is not too tight.
A nurse is contributing to the plan of care for a 5-week-old infant in the pediatric unit. The infant has been vomiting since week 2 of life and it has been progressively worse over the past 2 weeks. Parents report the vomiting is now forceful and projectile ('like a volcano erupting') immediately after every feeding, but the infant is eager to eat and seems to be constantly hungry. The infant has been receiving a cow's milk-based, iron-fortified formula since birth. The pediatrician reports the infant has not gained weight in the past 2 weeks. The last weight in the pediatrician's office is 3.54kg (8 lb). No other significant medical or surgical history. What condition is the client most likely experiencing and what actions should the nurse take to address that condition? What parameters should the nurse monitor to assess the client's progress?
- A. Gastroesophageal Reflux Disease (GERD), change the formula, monitor weight and feeding habits
- B. Pyloric Stenosis, refer for surgical consultation, monitor weight and vomiting frequency
- C. Lactose Intolerance, switch to lactose-free formula, monitor weight and stool consistency
- D. Milk Protein Allergy, switch to hypoallergenic formula, monitor weight and skin reactions
Correct Answer: B
Rationale: Gastroesophageal Reflux Disease (GERD) in infants is a condition where the stomach contents flow back into the esophagus causing discomfort. However, the symptoms described, such as projectile vomiting and constant hunger, are more consistent with Pyloric Stenosis. Pyloric Stenosis is a condition in infants where the opening from the stomach to the small intestine narrows, preventing food from entering the small intestine. The symptoms described by the parents, such as projectile vomiting after every feeding and constant hunger, align with this condition. The infant's lack of weight gain could be due to the fact that food is not being properly digested and absorbed. The nurse should refer the infant for a surgical consultation as the treatment for Pyloric Stenosis is usually surgical. The nurse should monitor the infant's weight and frequency of vomiting to assess the infant's progress. Lactose Intolerance in infants is a condition where the infant has difficulty digesting lactose, a sugar found in milk and dairy products. Symptoms can include gas, bloating, and diarrhea. However, the symptoms described by the parents do not align with this condition. Milk Protein Allergy in infants is a condition where the infant's immune system reacts negatively to the proteins in cow's milk. Symptoms can include hives, itching, wheezing, difficulty breathing, constipation, and bloody diarrhea. However, the symptoms described by the parents do not align with this condition.
A nurse is gathering information from a 1-year-old child who has been diagnosed with Wilms' tumor. Which of the following symptoms should the nurse anticipate?
- A. Jaundice
- B. Abdominal mass
- C. Swollen joints
- D. Diarrhea
Correct Answer: B
Rationale: Jaundice, a yellowing of the skin and eyes, is not typically a symptom of Wilms' tumor. It is more commonly associated with conditions that cause liver dysfunction. An abdominal mass is one of the most common symptoms of Wilms' tumor. Parents or healthcare providers may feel a lump or swelling in the child's abdomen. Swollen joints are not a typical symptom of Wilms' tumor. They are more commonly associated with conditions that affect the joints, such as juvenile arthritis. Diarrhea is not a typical symptom of Wilms' tumor. It is more commonly a symptom of gastrointestinal illnesses.
A nurse is providing care to a group of children at a pediatric clinic. Which of the following children meets the criteria to receive a varicella vaccine?
- A. A child who received a blood transfusion 1 month ago.
- B. A child currently receiving immunoglobulins.
- C. A child currently receiving chemotherapy.
- D. A child who has a cold and nasal discharge.
Correct Answer: D
Rationale: A child who received a blood transfusion 1 month ago is not recommended to receive the varicella vaccine. This is because blood transfusions can introduce new antibodies into the body that may interfere with the immune response to the vaccine. A child currently receiving immunoglobulins should not receive the varicella vaccine. Immunoglobulins are proteins in the blood that function as antibodies. They can interfere with the body's immune response to the vaccine. A child currently receiving chemotherapy should not receive the varicella vaccine. Chemotherapy can weaken the immune system, making it less effective at responding to vaccines. A child who has a cold and nasal discharge can receive the varicella vaccine. Mild illnesses, such as a cold, do not interfere with the immune response to the vaccine.