A patient is 1 hour postoperative following an open reduction internal fixation of the left tibia. Which of the following actions should the nurse take?

Correct Answer: A

Rationale: It is crucial to assess the neurovascular status of the extremities every 4 hours to monitor for any signs of complications such as impaired circulation or nerve damage. This frequent assessment helps in early detection of any issues that may arise postoperatively, allowing for timely intervention and prevention of potential complications.

Correct Answer: D

Rationale: Rheumatic fever can lead to cardiac complications, such as dysrhythmias. Therefore, it is essential for the nurse to monitor the child's heart rate closely for any signs of dysrhythmias. This will help in early identification and prompt management of potential cardiac issues associated with rheumatic fever.

Correct Answer: A

Rationale: During the oliguric phase of acute kidney injury, the priority is to manage fluid balance. Administering a loop diuretic helps promote diuresis and reduce fluid retention, aiding in managing the condition effectively. Providing a low-sodium diet may be beneficial but is not the priority intervention during this phase. Weighing the child weekly may be important for monitoring overall health but does not directly address the oliguric phase. Providing a high-protein diet is not typically recommended in acute kidney injury, especially during the oliguric phase.

Correct Answer: D

Rationale: The correct answer is option D: "I will massage my child's ear after administering the ear drops." This statement indicates an understanding of the teaching because gentle massage after administering ear drops helps to facilitate the distribution of the medication within the ear canal, ensuring optimal effectiveness. Option A is incorrect because pulling the ear canal upward and backward is not the correct technique for administering ear drops to a child. Option B is incorrect as administering cold ear drops directly from the refrigerator can cause discomfort and may lead to dizziness. Option C is also incorrect as pulling the ear lobe down and back is not the appropriate technique for administering ear drops to a child. In the context of pediatric nursing, it is crucial for parents to understand the correct technique for administering ear drops to ensure the safety and well-being of their child. Proper education on this topic can prevent complications and promote effective treatment of ear infections, highlighting the importance of clear and accurate instructions provided by healthcare professionals.

Correct Answer: B

Rationale: In caring for a school-age child with thrombocytopenia, which is a condition characterized by low platelet count and increased risk of bleeding, the nurse should prioritize interventions that minimize the risk of bleeding. Option B, avoiding venipunctures whenever possible, is the correct intervention to include in the plan. Venipunctures can lead to bleeding in children with thrombocytopenia, so minimizing unnecessary invasive procedures is essential to prevent complications. Option A, administering aspirin for fever, is incorrect because aspirin can further decrease platelet function and increase bleeding risk in these patients. Option C, encouraging participation in contact sports, is also incorrect as contact sports increase the risk of injury and bleeding, which is not safe for a child with thrombocytopenia. Option D, administering ibuprofen for pain, is not the best choice as ibuprofen can also affect platelet function and should be used cautiously in children with low platelet counts. Educationally, this rationale highlights the importance of understanding the specific needs of children with thrombocytopenia and the significance of implementing interventions that promote their safety and well-being. It underscores the nurse's role in providing holistic care and minimizing risks associated with the child's condition.