Nokea
A 1-year-old child is to receive an IM injection ordered by his pediatrician. He has fallen asleep in his mother's arms when the nurse approaches. Which approach is most appropriate at this time?
- A. Give the injection in the vastus lateralis site before the child awakens.
- B. Awaken the child first and give the injection in the ventrogluteal site.
- C. Awaken the child first and give the injection in the dorsogluteal site.
- D. Ask the mother to place the child on the examination table and leave the room, and then give the injection in an appropriate site.
Correct Answer: B
Rationale: If awakened first, the child will know that nothing painful will be done without the child being alerted. The ventrogluteal site is a safe site for children because it is a large muscle free of major nerves and blood vessels. The dorsogluteal site is not recommended in children who have not been walking for at least 1 year because the muscle is not fully developed. The parent will be able to offer support and comfort during and after the injection.
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Which of the following is not a step in primary assessment of a client presenting to the emergency department after being involved in a motor vehicle accident?
- A. Assessing and maintaining a patent airway
- B. Obtaining vital signs
- C. Using the Glasgow Coma Scale to check responsiveness
- D. Controlling bleeding
Correct Answer: B
Rationale: Primary assessment in trauma follows the ABCDE approach (Airway Breathing Circulation Disability Exposure). Obtaining vital signs is part of the secondary assessment not the primary survey which focuses on immediate life threats like airway bleeding and responsiveness.
The nurse is caring for a client with a history of congestive heart failure. The nurse should give priority to:
- A. Monitoring for arrhythmias
- B. Administering bronchodilators
- C. Monitoring for hyperglycemia
- D. Assessing for skin breakdown
Correct Answer: A
Rationale: Congestive heart failure increases the risk of arrhythmias due to cardiac strain, making monitoring for arrhythmias a priority to prevent sudden cardiac events.
The client is admitted with a diagnosis of gestational hypertension. Which vital sign change is most concerning?
- A. Blood pressure of 160/110
- B. Heart rate of 90 bpm
- C. Respiratory rate of 20 breaths per minute
- D. Temperature of 98.6°F
Correct Answer: A
Rationale: A blood pressure of 160/110 indicates severe gestational hypertension increasing the risk of complications like stroke or eclampsia and requires immediate intervention. The other vital signs are normal.
Parents of young children often need anticipatory guidance from the nurse. Parents may have little knowledge regarding growth and development. Which of the following toys and activities would the nurse suggest as appropriate for a toddler?
- A. Cutting, pasting, string beads, music, dolls
- B. Mobiles, rattle, squeeze toys
- C. Pull-toys, large ball, dolls, sand and water play, music
- D. Simple card games, puzzles, bicycle, television
Correct Answer: C
Rationale: These activities provide the toddler (1-3 years old) with a variety of physical activities for play, suitable for their developmental stage.
The nurse is caring for a client with a history of type 2 diabetes. The nurse should expect the client to have:
- A. Polyuria
- B. Weight loss
- C. Bradycardia
- D. Constipation
Correct Answer: A
Rationale: Type 2 diabetes causes hyperglycemia, leading to polyuria due to osmotic diuresis.