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

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?

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. What type of dehydration occurs when the electrolyte deficit exceeds the water deficit?

Correct answer: B

Rationale: Hypotonic dehydration occurs when the loss of electrolytes exceeds the loss of water, leading to a decrease in plasma osmolarity. This often occurs when sodium loss is greater than water loss, as in diarrhea or vomiting.

3. What are signs and symptoms of a possible kidney transplant rejection in a child? (Select all that apply.)

Correct answer: B

Rationale: Signs of kidney transplant rejection include fever, diminished urinary output, and swelling/tenderness in the graft area. These symptoms indicate that the body may be rejecting the transplanted organ, requiring immediate medical attention.

4. Which developmental milestone would the nurse expect an 11-month-old infant to have achieved?

Correct answer: A

Rationale: The correct answer is A: Sitting independently. By 11 months, most infants can sit independently. This milestone usually precedes walking, which typically occurs closer to 12 months. Turning a doorknob and building a tower of four cubes involve more complex motor skills that are typically achieved later in development. Therefore, at 11 months, sitting independently is the milestone that the nurse would expect an infant to have achieved.

5. What is the most effective way to prevent sudden infant death syndrome (SIDS)?

Correct answer: B

Rationale: The correct answer is to place the baby on their back to sleep. This position is the most effective way to prevent sudden infant death syndrome (SIDS) according to research and recommendations from healthcare providers. Choice A, using a firm mattress, is important for infant safety but not as directly related to preventing SIDS. Keeping the room warm, as mentioned in choice C, is not recommended as it may increase the risk of SIDS. While breastfeeding has many benefits, choice D, breastfeeding exclusively is not the most effective method for preventing SIDS.

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