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A nurse in an emergency department is caring for a 3-year-old child who has suspected epiglottitis. Which of the following actions should the nurse take?
- A. Prepare to assist with intubation.
- B. Obtain a throat culture.
- C. Suction the child's oropharynx.
- D. Prepare a cool mist tent
Correct Answer: A
Rationale: The correct answer is A: Prepare to assist with intubation. Epiglottitis is a medical emergency where the swelling of the epiglottis can rapidly obstruct the airway, leading to respiratory distress or failure. Intubation is crucial to secure the airway and ensure adequate oxygenation. Obtaining a throat culture (B) may delay necessary intervention. Suctioning the oropharynx (C) can trigger spasm and worsen the obstruction. Cool mist tent (D) does not address the immediate need for securing the airway.
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A nurse is teaching a newly licensed nurse about caring for clients in the emergency department. Which of the following actions should the nurse include when teaching about interacting with a client who is aggravated, pacing, and speaking loudly?
- A. Initiate seclusion protocol.
- B. Use a face shield with a mask when providing care to the client
- C. Tell the client, 'You seem to be very upset.'
- D. Engage the panic alarm
Correct Answer: C
Rationale: The correct answer is C. When a client is aggravated, pacing, and speaking loudly, it is important to acknowledge their feelings. By telling the client, "You seem to be very upset," the nurse shows empathy and validates the client's emotions. This can help de-escalate the situation by demonstrating understanding and openness to communication. It also allows the nurse to assess the client's needs and concerns effectively.
Choice A is incorrect as initiating seclusion protocol should only be considered for extreme cases where the client poses a danger to themselves or others. Choice B is unnecessary in this situation as it does not address the client's emotional state. Choice D, engaging the panic alarm, is premature and could escalate the situation further.
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. Postoperative pain management is crucial to ensure the child's comfort and facilitate recovery. Administering analgesics on a scheduled basis helps maintain a consistent level of pain relief and prevents breakthrough pain. This approach is especially important in the immediate postoperative period when pain levels are typically higher. Options A, C, and D are incorrect because applying a warm compress, giving cromolyn nebulized solution, and offering clear liquids are not primary interventions for postoperative pain management in this scenario. Option D specifically is not recommended as clear liquids are usually introduced gradually to prevent complications. Providing analgesics on a scheduled basis is the best course of action to address the child's immediate postoperative pain effectively.
A nurse is preparing to initiate intravenous fluids via infusion pump for a client. Which of the following actions should the nurse take?
- A. Obtain a surge protector that can accommodate the pump and several other appliances
- B. Verify that the extension cord for the pump is ungrounded
- C. Report the pump has a frayed cord and proceed with the infusion
- D. Check the expiration date on the safety inspection sticker of the pump
Correct Answer: D
Rationale: The correct answer is D: Check the expiration date on the safety inspection sticker of the pump. This is crucial for ensuring the safety and efficacy of the pump. Checking the expiration date ensures that the pump has been recently inspected and is functioning properly, reducing the risk of malfunctions.
A: Obtaining a surge protector is important for electrical safety, but it is not directly related to the specific task of initiating intravenous fluids via an infusion pump.
B: Verifying that the extension cord is ungrounded is unsafe as it increases the risk of electrical hazards.
C: Reporting a frayed cord is essential for patient safety, but proceeding with the infusion without addressing the issue is dangerous.
E, F, G: No information provided.
A nurse is performing a neurological examination on a client as part of a complete physical assessment. The nurse should identify that cranial nerve XI is intact when the client performs which of the following actions?
- A. Shrugs his shoulders
- B. Sticks his tongue out
- C. Frowns symmetrically
- D. Identifies a sour taste
Correct Answer: A
Rationale: The correct answer is A: Shrugs his shoulders. Cranial nerve XI, also known as the spinal accessory nerve, is responsible for controlling the trapezius and sternocleidomastoid muscles, which are involved in shoulder shrugging. When the nurse asks the client to shrug his shoulders against resistance, she is testing the integrity of cranial nerve XI. This action allows the nurse to assess the strength and function of this particular cranial nerve.
Choices B, C, and D are incorrect because they test other cranial nerves. Sticking the tongue out (B) tests cranial nerve XII (hypoglossal nerve), frowning symmetrically (C) tests cranial nerve VII (facial nerve), and identifying a sour taste (D) tests cranial nerve IX (glossopharyngeal nerve). These actions do not involve cranial nerve XI and are therefore not indicators of its intactness.
The nurse is assessing the client. Select the 4 findings that require immediate follow-up
- A. Hallucinations
- B. Heart rate
- C. Sleep pattern
- D. Skin turgor
- E. Hygiene
Correct Answer: A, B, D, E
Rationale: The correct answers are A, B, D, E. Hallucinations may indicate a serious mental health issue needing immediate attention. Heart rate abnormalities can signify cardiovascular problems. Skin turgor changes could indicate dehydration. Poor hygiene may suggest neglect or underlying health issues. Sleep pattern changes and personal grooming are important, but not typically requiring immediate follow-up.