A toddler is admitted to the surgical unit for a planned closure of a temporary colostomy. Which medical prescription should the nurse question?
1. Clear liquids today. NPO tomorrow
2. Type and cross-match for 1 unit of packed red blood cells.
3. Rectal temperatures every 4 hours
4. Start an intravenous line with D5NS at 20 mL per hour.
3
Explanation:
1. This is appropriate in anticipation of surgery.
2. Although not always required during surgery, this would not be inappropriate planning for the surgical procedure.
3. Rectal temperatures are avoided due to the fragile state of the rectum.
4. An IV is appropriate for surgical access.
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a. 30 minutes. b. 1 hour. c. 90 minutes. d. 2 hours.
Using an IV infusion system that delivers 60 drops/mL, the nurse hangs a 500-mL bag of NS at 8 AM. The physician has ordered a rate of 20 mL/hr. The nurse will set the roller clamp to deliver:
1. 10 gtts/minute. 2. 20 gtts/minute. 3. 25 gtts/minute. 4. 30 gtts/minute.
The nurse suspects clubfoot in the newborn and assesses for the condition by:
1. Adducting the foot and listening for a click. 2. Moving the foot to midline and determining resistance. 3. Extending the foot and observing for pain. 4. Stimulating the sole of the foot.
K.B. is transferred to the pediatric intensive care unit (PICu) and treated for changes in her neurologic sta-
tus. The next day her primary care provider determines that her condition is stable and has her transferred back to the pediatric unit. It is now 36 hours after surgery. K.B. suddenly begins to complain of extreme pain in her lower right leg. she had pain medication 2 hours ago and rates her pain as a 10 of 10. Which of these findings are early signs of compartment syndrome? Select all that apply. a. Diminished pedal pulse b. Macular rash c. Edema d. Paresthesia e. Capillary refill less than 2 seconds f. Increased pain