Nokea
A 10-year-old has 5 lb of Buck's extension traction on his left leg. The nurse should assess the child for which of the following? Select all that apply.
- A. Dryness of the skin, by removing the foam wraps and boot.
- B. Alignment of the shoulder, hips, and knees.
- C. Frayed rope near pulleys.
- D. Correct amount of traction weight on fracture.
- E. Pressure on the coccyx.
Correct Answer: B,C,D,E
Rationale: The nurse should check alignment, rope condition, weight accuracy, and pressure points to ensure effective and safe traction.
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The nurse is assisting another member of the health care team who is placing a peripherally inserted catheter in a 10-year-old with peritonitis from a ruptured appendix. The family is present in the treatment room to support the child. The nurse observes the other team member has contaminated a sterile glove. The nurse should:
- A. Discuss the incident with the team member after the event.
- B. Report the incident to the nursing unit manager.
- C. Tell the team member the glove is contaminated.
- D. Ask the family to leave before confronting the team member.
Correct Answer: C
Rationale: Immediately addressing the contamination maintains sterility and patient safety.
When developing the plan of care for a child who is unconscious after a serious head injury, in which of the following positions should the nurse expect to place the child?
- A. Prone with hips and knees slightly elevated.
- B. Lying on the side, with the head of the bed elevated.
- C. Lying on the back, in the Trendelenburg position.
- D. In the semi-Fowler's position, with arms at the side.
Correct Answer: B
Rationale: Side-lying with the head elevated reduces intracranial pressure and maintains airway patency in an unconscious child.
The nurse is teaching the parents of a child with sickle cell disease. To instruct them on how to prevent sickle cell crisis, she should include which instruction?
- A. Restrict the child's fluid intake to less than 1 quart per day.
- B. Start up a 1½ quarts of fluids per day.
- C. Stay away from other teenagers.
- D. Avoid physical activity.
Correct Answer: B
Rationale: Adequate hydration (1½ quarts daily) prevents blood viscosity, reducing the risk of sickle cell crisis. Other options are incorrect or overly restrictive.
Several high-school seniors are referred to the school nurse because of suspected alcohol misuse. When the nurse assesses the situation, what would be most important to determine?
- A. What they know about the legal implications of drinking.
- B. The type of alcohol they usually drink.
- C. The reasons they choose to use alcohol.
- D. When and with whom they use alcohol.
Correct Answer: C
Rationale: Understanding the reasons for alcohol use helps address underlying issues and tailor interventions.
Two months after an adolescent's thoracic spinal cord injury, he complains of a pounding headache. The nurse notes that the client's arms and face are flushed and he is diaphoretic. What should the nurse do next?
- A. Check the patency of the urinary catheter.
- B. Lower the adolescent's head below his knees.
- C. Place the adolescent flat on his back.
- D. Prepare to administer epinephrine subcutaneously.
Correct Answer: A
Rationale: These symptoms suggest autonomic dysreflexia, often triggered by bladder distension; checking the catheter is the first step.