Nokea
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.
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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 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.
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.
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.
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.