Nokea
A 2-year-old child is being admitted to the hospital for possible bacterial meningitis. When preparing for a lumbar puncture, what should the nurse do?
- A. Set up a tray with equipment the same size as for adults.
- B. Apply EMLA to the puncture site 15 minutes before the procedure.
- C. Prepare the child for conscious sedation being used for the procedure.
- D. Reassure the parents that the test is simple, painless, and risk free.
Correct Answer: C
Rationale: Conscious sedation is appropriate for a lumbar puncture in a 2-year-old with suspected bacterial meningitis due to the procedure?s urgency and need for cooperation. Adult-sized equipment is inappropriate, EMLA requires 60 minutes, and claiming the procedure is simple or painless is misleading.
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A nurse must do a venipuncture on a 6-year-old child. What consideration is important in providing atraumatic care?
- A. Use an 18-gauge needle if possible.
- B. Show the child the equipment to be used before the procedure.
- C. If not successful after four attempts, have another nurse try.
- D. Restrain the child completely.
Correct Answer: B
Rationale: Showing the child the equipment before the procedure reduces fear and supports atraumatic care. An 18-gauge needle is too large, a two-try policy (four attempts total) is preferred, and full restraint is unnecessary, favoring therapeutic hugging instead.
A 14-year-old adolescent is hospitalized with cystic fibrosis. What nursing note entry represents best documentation of his breakfast meal?
- A. Tolerated breakfast well
- B. Finished all of breakfast ordered
- C. One pancake, eggs, and 240 ml OJ
- D. No documentation is needed for this age child.
Correct Answer: C
Rationale: Documenting specific intake, like one pancake, eggs, and 240 ml orange juice, provides essential data for assessing caloric needs and eating patterns, critical for cystic fibrosis management. General statements like ?tolerated well? or ?finished all? lack detail, and documentation is always needed.
The nurse is preparing a 9-year-old boy before obtaining a blood specimen by venipuncture. The child tells the nurse he does not want to lose his blood. What approach is best by the nurse?
- A. Explain that it will not be painful.
- B. Suggest to him that he not worry about losing just a little bit of blood.
- C. Discuss with him how his body is always in the process of making blood.
- D. Tell the child that he will not even need a Band-Aid afterward because it is a simple procedure.
Correct Answer: C
Rationale: Explaining that the body continuously makes blood addresses the child?s fear of loss using age-appropriate scientific terms. Claiming it won?t hurt is inaccurate, dismissing worry doesn?t reassure, and minimizing the need for a Band-Aid trivializes the child?s concern.
A 6-year-old child needs to drink 1 L of GoLYTELY in preparation for a computed tomography scan of the abdomen. To encourage the child to drink, what should the nurse do?
- A. Give him a large cup with ice so it tastes better.
- B. Restrict him to his room until he drinks the GoLYTELY.
- C. Use little cups and make a game to reward him for each cup he drinks.
- D. Tell him that if he does not finish drinking by a set time, the practitioner will be angry.
Correct Answer: C
Rationale: Using small cups and making a game with rewards makes the large volume of GoLYTELY less daunting and encourages compliance. A large cup with ice increases the volume, restriction is punitive, and threats about the practitioner are ineffective and inappropriate.
A child who has cystic fibrosis is admitted to the pediatric unit with methicillin-resistant Staphylococcus aureus (MRSA) infection. The nurse recognizes that in addition to a private room, the child is placed on what precautions?
- A. Droplet
- B. Contact
- C. Airborne
- D. Standard
Correct Answer: B
Rationale: MRSA is spread by direct contact, requiring contact precautions with gowns, gloves, and meticulous hand washing, in addition to a private room. Droplet and airborne precautions are for different pathogens, and standard precautions alone are insufficient.