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Free NCLEX-RN Exam Braindumps (page: 169)

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PDF with 862 Questions

A 2-year-old child will undergo a cardiac catheterization tomorrow to evaluate his ventricular septal defect.
Based on his developmental stage, the nurse:

  1. Uses pictures to explain the procedure to the child and his parents that evening
  2. Explains the procedure using simple words and sentences just before the preoperative sedation
  3. Asks the parents to explain the procedure to the child after she explains it to them
  4. Asks the parents to leave the room while the preoperative medication and instructions are given

Answer(s): B

Explanation:

(A) A toddler is not capable of conceptualizing about the inside of his body and is concerned about body intactness; therefore, diagrams would not be useful. Also, the previous evening is too far from the procedure for the toddler to remember the instructions. (B) A simple explanation the morning of the procedure is the best developmental strategy to use, because it focuses on the toddler's need for parental support, body intactness, and short attention span. (C) A relationship between the nurse and the child needs to develop. Also, misinformation may be given to the child if the parents explain the procedure to the child. (D) The parents are the child's support system and need to be there to strengthen the child.



A 2-year-old child will undergo a cardiac catheterization tomorrow to evaluate his ventricular septal defect.
Based on his developmental stage, the nurse:

  1. Uses pictures to explain the procedure to the child and his parents that evening
  2. Explains the procedure using simple words and sentences just before the preoperative sedation
  3. Asks the parents to explain the procedure to the child after she explains it to them
  4. Asks the parents to leave the room while the preoperative medication and instructions are given

Answer(s): B

Explanation:

(A) A toddler is not capable of conceptualizing about the inside of his body and is concerned about body intactness; therefore, diagrams would not be useful. Also, the previous evening is too far from the procedure for the toddler to remember the instructions. (B) A simple explanation the morning of the procedure is the best developmental strategy to use, because it focuses on the toddler's need for parental support, body intactness, and short attention span. (C) A relationship between the nurse and the child needs to develop. Also, misinformation may be given to the child if the parents explain the procedure to the child. (D) The parents are the child's support system and need to be there to strengthen the child.



A client's transfusion of packed red blood cells has been infusing for 2 hours. She is complaining of a raised, itchy rash and shortness of breath. She is wheezing, anxious, and very restless. The nurse knows these assessment findings are congruent with:

  1. Hemolytic transfusion reaction
  2. Febrile transfusion reaction
  3. Circulatory overload
  4. Allergic transfusion reaction

Answer(s): D

Explanation:

(A) A hemolytic transfusion reaction would be characterized by fever, chills, chest pain, hypotension, and tachypnea. (B) Fever, chills, and headaches are indicative of a febrile transfusion reaction. (C) Circulatory overload is manifest by dyspnea, cough, and pulmonary crackles. (D) Urticaria, pruritus, wheezing, and anxiety are indicative of an allergic transfusion reaction.



A client's transfusion of packed red blood cells has been infusing for 2 hours. She is complaining of a raised, itchy rash and shortness of breath. She is wheezing, anxious, and very restless. The nurse knows these assessment findings are congruent with:

  1. Hemolytic transfusion reaction
  2. Febrile transfusion reaction
  3. Circulatory overload
  4. Allergic transfusion reaction

Answer(s): D

Explanation:

(A) A hemolytic transfusion reaction would be characterized by fever, chills, chest pain, hypotension, and tachypnea. (B) Fever, chills, and headaches are indicative of a febrile transfusion reaction. (C) Circulatory overload is manifest by dyspnea, cough, and pulmonary crackles. (D) Urticaria, pruritus, wheezing, and anxiety are indicative of an allergic transfusion reaction.






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