Question

The nurse is caring for the child 4 days after admission.

Exhibit 1
Graphic Record
0800:
Temperature 38.8° C (101.8° F)Heart rate 124/minRespiratory rate 22/minBlood pressure 100/56 mm HgSaO2 97% on room airWeight 17.1 kg (37.7 lb)Urine output 15 mL in past hour
Exhibit 2
Nurses' Notes
0800:
Child is awake, watching cartoons on television, and parent is at bedside. IV site in right antecubital is without redness or edema and dressing is dry and intact. Dressings to left arm and hand, anterior neck, and anterior chest are moderately saturated with serous drainage and several small spots of serosanguineous drainage. Dressings remain intact and smell malodorous.
Breath sounds are equal and clear bilaterally. Respirations are unlabored. Abdomen is soft and nondistended. Mucous membranes are moist. Skin turgor is slightly brisk.
Pupils are equal, round, and reactive to light and accommodation. Child is oriented to place, time, and name.
When child attempts to move, they begin to cry. Child reports pain as 8 on the FACES scale.
Noted a 1 cm x 2 cm stage 1 pressure injury on the right side of the occiput.
Prepared child and parent for transport to hydrotherapy and debridement scheduled for 0830
What should the nurse prioritize in the care of the child?
a) Administer pain relief medication for the child's reported pain level.
b) Examine the saturated dressings on the left arm and chest.
c) Prepare for hydrotherapy and debridement scheduled at 0830.
d) Address the stage 1 pressure injury on the occiput.

Answer 1

The nurse should prioritize addressing the stage 1 pressure injury on the occiput.

Step-by-step explanation:

In the care of the child, the nurse should prioritize d) addressing the stage 1 pressure injury on the occiput.

The child is reported to have a stage 1 pressure injury on the right side of the occiput. It is important for the nurse to address this injury promptly to prevent further complications and promote healing. This may include providing appropriate wound care, implementing measures to relieve pressure on the affected area, and assessing for signs of infection.

Administering pain relief medication for the child's reported pain level (option a) may be necessary, but addressing the pressure injury should be prioritized as it directly affects the child's physical well-being and potential for complications.

Examining the saturated dressings on the left arm and chest (option b) should also be done to assess for any infection or need for dressing changes, but it is not the highest priority compared to addressing the pressure injury.

Preparing for hydrotherapy and debridement scheduled at 0830 (option c) is important, but addressing the pressure injury should take precedence as it pertains to the immediate care of the child.