a 5 year old has patient controlled analgesia pca for pain management after abdominal surgery what information does the nurse include in teaching the

ATI RN

RN Nursing Care of Children 2019 With NGN

1. A 5-year-old has patient-controlled analgesia (PCA) for pain management after abdominal surgery. What information does the nurse include in teaching the parents about the PCA?

A. The child may not be pain-free.
B. The parents or nurse may push the button for a bolus if needed.
C. The pump allows for a continuous basal rate to deliver a constant amount of medication for pain control.
D. Monitoring is required every 1 to 2 hours to assess patient response.

Correct answer: C

Rationale: The correct answer is C because the PCA pump can be programmed to deliver a continuous basal rate of pain medication to maintain pain control. While the goal of PCA is effective pain relief, it does not guarantee a pain-free state. In the case of a 5-year-old child, the parents or nurse can administer boluses if necessary since the child may not fully comprehend using the PCA button. Monitoring every 1 to 2 hours for patient response is adequate and there is no need for monitoring every 15 minutes, as stated in choice D, unless specific circumstances dictate more frequent monitoring.

2. Latex allergy is suspected in a child with spina bifida. What are appropriate nursing interventions to include in care of this patient?

A. Avoid using any latex product.
B. Use only non-allergenic latex products.
C. Teach the family about long-term management of asthma.
D. Administer medication for long-term desensitization.

Correct answer: A

Rationale: The correct answer is A: 'Avoid using any latex product.' In the case of a suspected latex allergy, it is crucial to prevent exposure to latex products to avoid allergic reactions. Choice B is incorrect because there are no truly non-allergenic latex products. Choice C is irrelevant to the situation described in the question, as the child does not have asthma. Choice D is also incorrect because desensitization is not an immediate option for managing a suspected latex allergy.

3. Rectal temperatures are indicated in which situation?

A. In the newborn period
B. Whenever accuracy is essential
C. Rectal temperatures are never indicated
D. When rapid temperature changes are occurring

Correct answer: B

Rationale: Rectal temperatures provide the most accurate measurement of core body temperature and are therefore indicated when accuracy is essential.

4. A Hispanic toddler has pneumonia. The nurse notices that the parent consistently feeds the child only the broth that comes on the clear liquid tray. Food items, such as Jell-O, Popsicles, and juices, are left. Which statement best explains this?

A. The parent is trying to feed the child only what the child likes most
B. Hispanics believe the evil eye enters when a person gets cold
C. The parent is trying to restore normal balance through appropriate hot remedies
D. Hispanics believe an innate energy called chi is strengthened by eating soup

Correct answer: C

Rationale: In Hispanic culture, the balance between hot and cold is important, and the parent may be giving the child broth to restore this balance while avoiding "cold" foods.

5. At which age do most infants begin to fear strangers?

A. 2 months
B. 4 months
C. 6 months
D. 12 months

Correct answer: C

Rationale: Fear of strangers typically begins around 6 months as infants start recognizing familiar and unfamiliar faces, which is part of their social development.