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A 5-year-old child returns from the pediatric intensive care unit after abdominal surgery. The orders state to monitor vital signs every 2 hours. On assessment, the nurse observes that the childs heart rate is 20 beats/min less than it was preoperatively. What should be the nurses next action?
- A. Follow the orders and check in 2 hours.
- B. Ask the parents if this is the childs usual heart rate.
- C. Recheck the pulse and blood pressure in 15 minutes.
- D. Notify the surgeon that the child is probably going into shock.
Correct Answer: C
Rationale: A 20 beats/min decrease in heart rate is significant and warrants rechecking pulse and blood pressure in 15 minutes to assess stability. Waiting 2 hours delays intervention, parents may not know the usual rate, and assuming shock without further data is premature.
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A child, age 7 years, has a fever associated with a viral illness. She is being cared for at home. What is the principal reason for treating fever in this child?
- A. Relief of discomfort
- B. Reassurance that illness is temporary
- C. Prevention of secondary bacterial infection
- D. Avoidance of life-threatening complications
Correct Answer: A
Rationale: Treating fever primarily relieves discomfort using antipyretics and environmental measures. It doesn?t reassure temporariness, prevent bacterial infections, or significantly reduce rare complications like febrile seizures.
The nurse gives an injection in a patients room. How should the nurse dispose of the needle?
- A. Remove the needle from the syringe and dispose of it in a proper container.
- B. Dispose of the syringe and needle in a rigid, puncture-resistant container in the patients room.
- C. Close the safety cover on the needle and return it to the medication preparation area for proper disposal.
- D. Place the syringe and needle in a rigid, puncture-resistant container in an area outside of the patients room.
Correct Answer: B
Rationale: Disposing of the syringe and needle in a rigid, puncture-resistant container in the patient?s room ensures safe, immediate disposal near the point of use. Removing the needle, transporting it, or disposing outside the room increases risk of injury or contamination.
A 10-year-old child requires daily medications for a chronic illness. Her mother tells the nurse that the child continually forgets to take the medicine unless reminded. What nursing action is most appropriate to promote adherence to the medication regimen?
- A. Establish a contract with her, including rewards.
- B. Suggest time-outs when she forgets her medicine.
- C. Discuss with her mother the damaging effects of her rescuing the child.
- D. Ask the child to bring her medicine containers to each appointment so they can be counted.
Correct Answer: A
Rationale: Establishing a behavioral contract with rewards encourages adherence by addressing barriers like side effects or scheduling and motivates the child. Time-outs are punitive, discussing maternal rescuing is less effective, and checking containers monitors but doesn?t promote self-responsibility.
A 4-year-old girl is admitted to outpatient surgery for removal of a cyst on her back. Her mother puts the hospital gown on her, but the child is crying because she wants to leave on her underpants. What is the most appropriate nursing action at this time?
- A. Allow her to wear her underpants.
- B. Discuss with her mother why this is important to the child.
- C. Ask her mother to explain to her why she cannot wear them.
- D. Explain in a kind, matter-of-fact manner that this is hospital policy.
Correct Answer: A
Rationale: Allowing the child to keep her underpants on provides a sense of control and comfort, and they can be removed later if needed for anesthesia. Discussing with the mother or citing hospital policy doesn?t address the child?s distress, and asking the mother to explain may escalate the situation.
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.