Nokea
A 4-year-old child is brought to the emergency department with a suspected fracture. What is the priority nursing action?
- A. Immobilize the affected limb
- B. Apply ice to the affected area
- C. Elevate the affected limb
- D. Check the child's neurovascular status
Correct Answer: A
Rationale: The priority nursing action when a child with a suspected fracture is brought to the emergency department is to immobilize the affected limb. Immobilization helps prevent further injury until a fracture is confirmed or ruled out. Applying ice or elevating the limb can wait until after immobilization has been achieved. Checking the child's neurovascular status is important but is not the priority action in this situation.
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A child with a diagnosis of pyloric stenosis is scheduled for surgery. What preoperative intervention is important for the nurse to perform?
- A. Administering intravenous fluids
- B. Monitoring for signs of infection
- C. Monitoring for signs of dehydration
- D. Monitoring for signs of pain
Correct Answer: C
Rationale: The correct preoperative intervention for a child with pyloric stenosis is to monitor for signs of dehydration. Pyloric stenosis involves the obstruction of the pyloric sphincter, leading to projectile vomiting, which can result in dehydration and electrolyte imbalances. Monitoring for signs of dehydration is crucial to assess the child's fluid status and prevent complications. Administering intravenous fluids, although important in managing dehydration, is not typically a preoperative intervention but rather a treatment during or after surgery. Monitoring for signs of infection and pain may also be important but are not the priority preoperative interventions in a child with pyloric stenosis.
The nurse is implementing care for a school-age child admitted to the pediatric intensive care unit with diabetic ketoacidosis (DKA). Which prescribed intervention should the nurse implement first?
- A. Begin 0.9% saline solution intravenously as prescribed
- B. Administer regular insulin intravenously as prescribed
- C. Place child on a cardiac monitor
- D. Place child on a pulse oximetry monitor
Correct Answer: A
Rationale: Initiating intravenous saline solution is the initial priority in managing diabetic ketoacidosis to address dehydration and electrolyte imbalances. Administering insulin without addressing dehydration first can lead to potential complications. While monitoring cardiac status and oxygen saturation are important, addressing the fluid and electrolyte imbalances takes precedence in the management of DKA.
A parent arrives in the emergency clinic with a 3-month-old baby who says, "My baby stopped breathing for a while." The infant continues to have difficulty breathing, with prolonged periods of apnea. Which assessment data should alert the nurse to suspect shaken baby syndrome (SBS)?
- A. Birth occurred before 32 weeks' gestation
- B. Lack of stridor and adventitious breath sounds
- C. Previous episodes of apnea lasting 10 to 15 seconds
- D. Retractions and use of accessory respiratory muscles
Correct Answer: D
Rationale: Retractions and the use of accessory respiratory muscles can be signs of respiratory distress, which may indicate trauma such as shaken baby syndrome (SBS). Shaken baby syndrome can result in brain injury and respiratory compromise, leading to breathing difficulties. Choices A, B, and C are less likely to be associated with SBS. Birth before 32 weeks' gestation is more related to prematurity rather than SBS. The lack of stridor and adventitious breath sounds, as well as previous episodes of apnea lasting 10 to 15 seconds, are not specific indicators of SBS.
A 4-year-old child is brought to the emergency department with a suspected fracture. What is the priority nursing action?
- A. Immobilize the affected limb
- B. Apply ice to the affected area
- C. Elevate the affected limb
- D. Check the child's neurovascular status
Correct Answer: A
Rationale: The priority nursing action when a child with a suspected fracture is brought to the emergency department is to immobilize the affected limb. Immobilization helps prevent further injury until a fracture is confirmed or ruled out. Applying ice or elevating the limb may be necessary interventions but should come after immobilizing the limb. Checking the child's neurovascular status is important but should follow immobilization to ensure no further harm is done during the assessment.
A child with a diagnosis of cystic fibrosis is admitted to the hospital. What is the priority nursing intervention?
- A. Administering pancreatic enzymes
- B. Providing respiratory therapy
- C. Providing nutritional support
- D. Encouraging physical activity
Correct Answer: A
Rationale: The correct answer is administering pancreatic enzymes. In cystic fibrosis, there is a deficiency in pancreatic enzymes, leading to poor digestion and malabsorption of nutrients. Administering pancreatic enzymes is essential to ensure proper digestion and absorption of nutrients. Providing respiratory therapy and nutritional support are important aspects of care for a child with cystic fibrosis, but addressing the pancreatic enzyme deficiency takes priority in this scenario. Encouraging physical activity is beneficial for overall health but is not the priority intervention in this case.