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A nurse is preparing to administer eye drops to a school-age child. Identify the actions the nurse should take.
- A. Apply pressure to the lacrimal punctum.
- B. Place the child in a sitting position.
- C. Instill the drops of medication.
- D. Pull the lower eyelid downward.
- E. Ask the child to look upward.
Correct Answer: B,C,D,E
Rationale: The correct order is B, C, D, E. First, placing the child in a sitting position ensures safety and easy access to the eyes. Next, instilling the drops of medication into the conjunctival sac is essential for proper administration. Then, pulling the lower eyelid downward helps to create a pocket for the drops to be placed. Finally, asking the child to look upward aids in the proper distribution of the medication. Choice A is incorrect as applying pressure to the lacrimal punctum is not necessary for administering eye drops. Choices F and G are not applicable in this scenario.
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A nurse is providing teaching about home safety to the adult child of an older adult client who is postoperative following knee replacement surgery. Which of the following instructions should the nurse include?
- A. Encourage the client to avoid wearing shoes at home.
- B. Ensure that area rugs have rubber backs.
- C. Mark the edges of the doorway to the house with tape.
- D. Place a throw rug over electrical cords.
Correct Answer: B
Rationale: The correct answer is B: Ensure that area rugs have rubber backs. This instruction is important to prevent slips and falls, especially for an older adult recovering from knee replacement surgery. Rubber-backed rugs provide traction and stability, reducing the risk of accidents. Encouraging the client to avoid wearing shoes at home (A) may increase the risk of slipping on smooth surfaces. Marking the edges of the doorway with tape (C) may not be effective and could create a tripping hazard. Placing a throw rug over electrical cords (D) is unsafe as it can cause the older adult to trip.
A nurse is assessing a child who has bacterial pneumonia. Which of the following manifestations should the nurse expect?
- A. Steatorrhea
- B. Fever
- C. Drooling
- D. Tinnitus
Correct Answer: B
Rationale: The correct answer is B: Fever. In bacterial pneumonia, the body's immune response leads to fever as a common manifestation due to the infection. This is because the body is trying to fight off the bacterial invasion. Steatorrhea (A) is not typically associated with bacterial pneumonia. Drooling (C) is more commonly seen in conditions affecting the mouth or throat. Tinnitus (D) is a symptom related to the ears and is not typically associated with pneumonia. Therefore, the presence of fever is the most relevant sign in a child with bacterial pneumonia.
A nurse is planning care for a toddler who has epiglottitis. Which of the following interventions should the nurse include?
- A. Offer a high-calorie, high-protein diet.
- B. Administer pancreatic enzymes with meals.
- C. Initiate droplet precautions.
- D. Carefully suction the child's oropharynx to remove secretions.
Correct Answer: C
Rationale: The correct answer is C: Initiate droplet precautions. Epiglottitis is a serious condition that involves inflammation of the epiglottis, which can lead to airway obstruction. Droplet precautions are necessary to prevent the spread of infection, as epiglottitis is usually caused by a bacterial infection. Offering a high-calorie, high-protein diet (choice A) is not the priority in the acute phase of epiglottitis. Administering pancreatic enzymes with meals (choice B) is unrelated to the care of a toddler with epiglottitis. Carefully suctioning the child's oropharynx to remove secretions (choice D) can potentially worsen the condition by triggering a gag reflex and causing further airway obstruction.
A nurse is planning care for a school-age child who is 4 hr postoperative following appendicitis. Which of the following actions should the nurse include in the plan of care?
- A. Apply a warm compress to the operative site once daily.
- B. Administer analgesics on a scheduled basis for the first 24 hr.
- C. Give cromolyn nebulized solution every 8 hr.
- D. Offer small amounts of clear liquids 6 hr following surgery.
Correct Answer: B
Rationale: The correct answer is B: Administer analgesics on a scheduled basis for the first 24 hr.
Rationale: Postoperative pain management is crucial for the comfort and recovery of the child. Administering analgesics on a scheduled basis helps control pain effectively and prevents breakthrough pain. The first 24 hours following surgery are critical for pain control as the child may experience increased discomfort during this time. By providing analgesics on a schedule, the nurse ensures that the child receives timely pain relief.
Summary of incorrect choices:
A: Applying a warm compress to the operative site is not a standard practice post-appendectomy and may not effectively manage pain.
C: Cromolyn nebulized solution is not typically used for pain management post-appendectomy.
D: Offering clear liquids 6 hours following surgery may not be appropriate as the child may not be ready to tolerate oral intake so soon after surgery.
A nurse is assessing a school-age child who is receiving prednisone. For which of the following adverse effects should the nurse monitor?
- A. Renal failure
- B. Stevens-Johnson syndrome
- C. Prolonged wound healing
- D. Hypotension
Correct Answer: C
Rationale: The correct answer is C: Prolonged wound healing. Prednisone is a corticosteroid that can suppress the immune system and delay wound healing due to its anti-inflammatory effects. The nurse should monitor for this adverse effect by assessing the child's wounds regularly for signs of slow or impaired healing. Renal failure (A) is not a common adverse effect of prednisone. Stevens-Johnson syndrome (B) is a severe skin reaction usually caused by medications but is not typically associated with prednisone. Hypotension (D) is not a common adverse effect of prednisone and is more commonly associated with other medications or conditions.