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A preschool age child undergoing endotracheal suctioning
A charge nurse is observing a newly licensed nurse who is performing endotracheal suctioning for a preschool age child. Which of the following actions by the newly licensed nurse requires the charge nurse to intervene?
- A. Applying suction for 20 seconds
- B. Introducing the catheter without suction
- C. Rotating the catheter between the thumb and forefinger while suctioning
- D. Allowing the child to rest for 30 to 60 seconds between suctioning passes
Correct Answer: B
Rationale: The correct answer is B: Introducing the catheter without suction. When performing endotracheal suctioning, it is crucial to apply suction while introducing the catheter to effectively remove secretions. Introducing the catheter without suction can result in ineffective suctioning and potential harm to the child.
A: Applying suction for 20 seconds is within the recommended time frame for suctioning.
C: Rotating the catheter while suctioning helps to ensure thorough removal of secretions.
D: Allowing the child to rest between suctioning passes is important to prevent hypoxia and maintain oxygenation.
In summary, choice B is incorrect because it goes against the fundamental principle of effective suctioning, while choices A, C, and D are all appropriate actions during endotracheal suctioning for a preschool-age child.
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Which of the following techniques help prepare a child for surgery by utilising role playing or hands on activities (eg, starting an IV on a teddy bears)?
- A. Onlooker play
- B. Therapeutic play
- C. Cooperative play
- D. Play therapy
Correct Answer: B
Rationale: The correct answer is B: Therapeutic play. Therapeutic play involves using various activities like role-playing or hands-on tasks to help children understand and cope with medical procedures. It allows them to express emotions, reduce anxiety, and gain a sense of control. Onlooker play (A) involves observing others play without actively participating. Cooperative play (C) involves playing together towards a common goal. Play therapy (D) is a form of psychotherapy using play to help children express feelings. Since the question specifically mentions preparing a child for surgery through role-playing and hands-on activities, therapeutic play is the most appropriate choice.
An adolescent who is having a sickle cell crisis
A nurse is caring for an adolescent who is having a sickle cell crisis. Which of the following nursing actions should the nurse take?
- A. withhold opioids to avoid dependence
- B. Assist RN with administering a blood transfusion
- C. Initiate a 2 L/day fluid restriction
- D. Encourage exercise
Correct Answer: B
Rationale: The correct answer is B: Assist RN with administering a blood transfusion. During a sickle cell crisis, blood transfusions can help improve oxygen delivery to tissues by increasing the number of normal red blood cells. This can help alleviate symptoms and prevent complications. Withholding opioids (choice A) can lead to inadequate pain management. Initiation of fluid restriction (choice C) is inappropriate as hydration is crucial during a sickle cell crisis. Encouraging exercise (choice D) can worsen the crisis by increasing the risk of vaso-occlusive events.
A 9-year-old child who has acute rheumatic fever
A nurse is assisting with the admission of a 9-year-old child who has acute rheumatic fever. When obtaining the client's history, it is appropriate for the nurse to ask the parent which of the following questions?
- A. Has your son had a sore throat recently?
- B. Was your son born with this cardiac defect?
- C. Are you aware that your son will have to be in isolation?
- D. Has your child had any injuries recently?
Correct Answer: A
Rationale: Rationale: A sore throat can be a symptom of acute rheumatic fever, which is important for the nurse to assess. This can help in diagnosing the condition and planning appropriate care. Asking about a recent sore throat is relevant to the child's current health status and can guide further assessment and treatment.
Summary:
B: This question is not relevant to acute rheumatic fever.
C: Isolation is not necessary for acute rheumatic fever, so this question is not appropriate.
D: Recent injuries are not directly related to acute rheumatic fever and are not relevant to the child's current condition.
An infant who has spina bifida
A nurse is caring for an infant who has spina bifida. Which of the following actions should the nurse take?
- A. Place the infant in prone position.
- B. Cover the infant's lesion with a dry cloth.
- C. Feed the infant through an NG tube.
- D. Diapering over a low defect will keep the infant free from infection
Correct Answer: D
Rationale: The correct answer is D. Diapering over a low defect will keep the infant free from infection. This is because keeping the area covered with a diaper helps prevent contamination and infection. Placing the infant in prone position (choice A) is not recommended as it can put pressure on the lesion. Covering the lesion with a dry cloth (choice B) may not provide adequate protection from contamination. Feeding the infant through an NG tube (choice C) is not directly related to preventing infection at the lesion site. Therefore, the best option is to diaper over the defect to maintain hygiene and prevent infection.
A child who is experiencing an acute asthma attack
A nurse is caring for a child who is experiencing an acute asthma attack. Which of the following medications should the nurse administer first?
- A. Methylprednisolone
- B. Albuterol
- C. Fluticasone
- D. Beclomethasone
Correct Answer: B
Rationale: The correct answer is B: Albuterol. During an acute asthma attack, bronchodilation is crucial to relieve airway constriction quickly. Albuterol is a short-acting beta-agonist that acts rapidly to relax the airway muscles, allowing for improved airflow. Methylprednisolone (A) is a corticosteroid that is used for long-term control, not for immediate relief. Fluticasone (C) and Beclomethasone (D) are inhaled corticosteroids for maintenance therapy and do not provide immediate relief during an acute attack. Administering Albuterol first is essential to address the acute symptoms and stabilize the child's condition.