latex allergy is suspected in a child with spina bifida what are appropriate nursing interventions to include in care of this patient

ATI RN

Nursing Care of Children ATI

1. 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.

2. 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.

3. What is the best indicator of fluid balance in a pediatric patient?

A. Blood pressure
B. Heart rate
C. Weight
D. Urine output

Correct answer: C

Rationale: Weight is the most accurate indicator of fluid balance in pediatric patients. Changes in weight reflect shifts in body fluid levels more directly compared to other parameters. Blood pressure and heart rate may be affected by various factors other than fluid balance. While urine output is important in assessing renal function, it may not provide a comprehensive picture of overall fluid balance in pediatric patients.

4. An intravenous line is needed in a school-age child. What medication is an appropriate analgesic for use with this patient?

A. TAC (tetracaine, epinephrine [Adrenalin], cocaine) 15 minutes before the procedure.
B. A transdermal fentanyl (Duragesic) patch at the site of venipuncture.
C. EMLA (eutectic mixture of local anesthetics) immediately before the procedure.
D. LMX (4% liposomal lidocaine cream) 30 minutes before the procedure.

Correct answer: D

Rationale: LMX is an effective analgesic agent when applied to the skin 30 minutes before a procedure. It eliminates or reduces the pain from most procedures involving skin puncture. TAC provides skin anesthesia about 15 minutes after application to nonintact skin, making it more suitable for wound suturing. Transdermal fentanyl patches are designed for continuous pain control, not rapid pain control needed for a procedure like venipuncture. EMLA, for maximum effectiveness, must be applied approximately 60 minutes before the procedure, making it less suitable for immediate pain relief required for intravenous line placement.

5. Nursing care of children focuses on improving quality by:

A. Improving sanitation
B. Focusing on curing childhood illnesses
C. Addressing problems caused by communicable disease
D. Providing a holistic environment for optimal growth and development

Correct answer: D

Rationale: The correct answer is D because nursing care for children should encompass a holistic approach that considers not only physical health but also emotional, social, and developmental aspects. Providing a holistic environment promotes optimal growth and development by addressing all these dimensions. Choices A, B, and C are incorrect because while sanitation, curing illnesses, and addressing communicable diseases are important aspects of child healthcare, they do not encompass the comprehensive care provided by a holistic approach.