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Question
A nurse is assisting with the care of a school-age child following an appendectomy.
Exhibit 1
Vital Signs
Day 0:
Temperature 37.1° C (98.8° F)
Heart rate 100/min
Respiratory rate 20/min
ST
Blood pressure 94/60 mm Hg
Oxygen saturation 97% on room air
Day 1:
Temperature 38.6° C (101.5° F)
U
Heart rate 110/min
Respiratory rate 24/min
D
Blood pressure 100/60 mm Hg
Oxygen saturation 95% on room air
YL
Exhibit 2
Nurses' Notes
Day 0:
AB
Child is drowsy, but easily roused and responsive to verbal stimuli. Child rates pain as a 4 on a scale of
0 to 10. Lungs are clear upon auscultation. Abdomen is soft, flat, and nondistended. Bowel sounds are
hypoactive in all four quadrants. Extremities are warm and dry to touch. Gauze pads with clear
transparent dressings noted on upper, lower, and left mid-umbilical area.
Day 1:
Child is alert and responsive to verbal stimuli. Appears irritable and restless. Child rates pain as an 8
on a scale of 0 to 10. Respirations are shallow. No accessory muscle use noted. Lungs are clear upon
auscultation. Abdomen is rigid and distended. Bowel sounds are hypoactive in all four quadrants.
Gauze pads with clear transparent dressings noted to upper, lower, and left mid-umbilical area.
Dressings have scant amount of serous drainage present. Extremities are cool and dry to touch
Diagnostic Results
Day 0:
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Hgb 12 g/dL (10 to 15.5 g/dL) Hct 38% (32% to 44%)
WBC count 16,000/mm³ (5,000 to 10,000 mm³)
Platelets 350,000/mm³ (150,000 to 400,000/mm³)
Day 1:
Hgb 10.5 g/dL (10 to 15.5 g/dL)
Hct 34% (32% to 44%)
WBC count 24,000/mm³ (5,000 to 10,000 mm³)
Platelets 280,000/mm³ (150,000 to 400,000/mm³)
ST
Select the 3 findings that the nurse should identify as indications of a potential complication.
Abdominal assessment
U
Oxygen saturation
Temperature
D
Platelet count
Abdominal dressings assessment
YL
WBC count
Question
A nurse is collecting data from a 6-month-old child who is experiencing a sickle cell crisis. Which of the
following areas should the nurse observe when monitoring for manifestations of splenic
sequestration? (You will find hot spots to select in the artwork below. Select only the hot spot that
AB
corresponds to your answer.)
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ST
U
D
YL
Correct hot spot: B
Question
A nurse in a community center is reinforcing teaching about poison control with a group of parents.
AB
Identify the sequence of actions the nurse should recommend to the parent. (Move the steps into the
box on the right, placing them in the order of performance. All steps must be used.)
Identify the medication and dosage strength.
Determine if the child is breathing.
Empty the child's mouth of remaining pills and residue.
Call a poison control center.
Correct order:
Empty the child's mouth of remaining pills and residue.
Determine if the child is breathing.
Identify the medication and dosage strength.
Call a poison control center.
jhgfdsa
Question
A nurse is assisting with the care of a school-age child following an appendectomy.
Exhibit 1
Vital Signs
Day 0:
Temperature 37.1° C (98.8° F)
Heart rate 100/min
Respiratory rate 20/min
ST
Blood pressure 94/60 mm Hg
Oxygen saturation 97% on room air
Day 1:
Temperature 38.6° C (101.5° F)
U
Heart rate 110/min
Respiratory rate 24/min
D
Blood pressure 100/60 mm Hg
Oxygen saturation 95% on room air
YL
Exhibit 2
Nurses' Notes
Day 0:
AB
Child is drowsy, but easily roused and responsive to verbal stimuli. Child rates pain as a 4 on a scale of
0 to 10. Lungs are clear upon auscultation. Abdomen is soft, flat, and nondistended. Bowel sounds are
hypoactive in all four quadrants. Extremities are warm and dry to touch. Gauze pads with clear
transparent dressings noted on upper, lower, and left mid-umbilical area.
Day 1:
Child is alert and responsive to verbal stimuli. Appears irritable and restless. Child rates pain as an 8
on a scale of 0 to 10. Respirations are shallow. No accessory muscle use noted. Lungs are clear upon
auscultation. Abdomen is rigid and distended. Bowel sounds are hypoactive in all four quadrants.
Gauze pads with clear transparent dressings noted to upper, lower, and left mid-umbilical area.
Dressings have scant amount of serous drainage present. Extremities are cool and dry to touch
Diagnostic Results
Day 0:
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, jhgfdsa
Hgb 12 g/dL (10 to 15.5 g/dL) Hct 38% (32% to 44%)
WBC count 16,000/mm³ (5,000 to 10,000 mm³)
Platelets 350,000/mm³ (150,000 to 400,000/mm³)
Day 1:
Hgb 10.5 g/dL (10 to 15.5 g/dL)
Hct 34% (32% to 44%)
WBC count 24,000/mm³ (5,000 to 10,000 mm³)
Platelets 280,000/mm³ (150,000 to 400,000/mm³)
ST
Select the 3 findings that the nurse should identify as indications of a potential complication.
Abdominal assessment
U
Oxygen saturation
Temperature
D
Platelet count
Abdominal dressings assessment
YL
WBC count
Question
A nurse is collecting data from a 6-month-old child who is experiencing a sickle cell crisis. Which of the
following areas should the nurse observe when monitoring for manifestations of splenic
sequestration? (You will find hot spots to select in the artwork below. Select only the hot spot that
AB
corresponds to your answer.)
jhgfdsa
, jhgfdsa
ST
U
D
YL
Correct hot spot: B
Question
A nurse in a community center is reinforcing teaching about poison control with a group of parents.
AB
Identify the sequence of actions the nurse should recommend to the parent. (Move the steps into the
box on the right, placing them in the order of performance. All steps must be used.)
Identify the medication and dosage strength.
Determine if the child is breathing.
Empty the child's mouth of remaining pills and residue.
Call a poison control center.
Correct order:
Empty the child's mouth of remaining pills and residue.
Determine if the child is breathing.
Identify the medication and dosage strength.
Call a poison control center.
jhgfdsa
