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A nurse is caring for a school-age child who is postoperative and received morphine via IV bolus for pain 10 min ago. Which of the following findings is the nurse's priority?
- A. Constipation
- B. Sedation
- C. Bradypnea
- D. Euphoria
Correct Answer: C
Rationale: The correct answer is C: Bradypnea. This is the priority finding because morphine, an opioid, can cause respiratory depression leading to bradypnea or slow breathing. Monitoring the child's respiratory status is crucial to prevent respiratory compromise or arrest. A: Constipation is a common side effect but not an immediate concern. B: Sedation is expected after receiving morphine but not as critical as respiratory depression. D: Euphoria is a possible side effect but not as concerning as respiratory depression. Thus, the priority is to monitor for signs of respiratory depression to ensure the child's safety.
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Which explanation regarding cardiac catheterization is appropriate for a preschool child?
- A. Postural drainage will be performed every 4 to 6 hours after the test
- B. It is necessary to be completely asleep during the test
- C. The test is short, usually taking less than 1 hour
- D. When the procedure is done, you will have to keep your leg straight until after dinnertime
Correct Answer: D
Rationale: The correct answer is D because preschool children may not fully understand the importance of keeping still after cardiac catheterization. Keeping the leg straight helps prevent bleeding at the insertion site. Choice A is incorrect as postural drainage is not related to cardiac catheterization. Choice B is incorrect as sedation, not complete sleep, is usually used. Choice C is incorrect as the procedure can take longer than an hour.
A nurse is caring for a school-age child who is 2 hr postoperative following a cardiac catheterization. The nurse observes blood on the child's dressing. Which of the following actions should the nurse take?
- A. Apply intermittent pressure 2.5 cm (1 in) below the percutaneous skin site.
- B. Apply continuous pressure 2.5 cm (1 in) above the percutaneous skin site.
- C. Apply continuous pressure 2.5 cm (1 in) below the percutaneous skin site.
- D. Apply intermittent pressure 2.5 cm (1 in) above the percutaneous skin site.
Correct Answer: C
Rationale: Correct Answer: C
Rationale: Applying continuous pressure 2.5 cm below the percutaneous skin site will help control bleeding by promoting clot formation at the catheter insertion site. This pressure point is closer to the source of bleeding, ensuring better hemostasis and preventing further complications.
Summary:
A: Applying intermittent pressure below the site is incorrect as continuous pressure is more effective in achieving hemostasis.
B: Applying continuous pressure above the site is incorrect as it does not target the bleeding source directly.
D: Applying intermittent pressure above the site is incorrect as continuous pressure is preferred for controlling bleeding.
E, F, G: No information provided.
The nurse is providing education to parents of a toddler that will receive an iron supplement to treat iron deficiency anaemia. Which statement indicates the parents need further teaching?
- A. It's important to rinse my baby's mouth out with water immediately after giving her the iron
- B. We need to store the iron in a safe place because an accidental overdose can be toxic to the baby
- C. If we notice dark green stools, we should immediately notify the doctor.
- D. A good way to prevent iron deficiency anaemia is to limit the baby's milk consumption to 32 ounces per day.
Correct Answer: C
Rationale: The correct answer is C. If parents notice dark green stools after giving iron supplements, it is actually a common and harmless side effect due to the iron's color. They do not need to immediately notify the doctor unless there are other concerning symptoms. Rinsing the baby's mouth after giving iron (A) is important to prevent staining. Storing iron safely (B) is crucial to prevent accidental ingestion. Limiting milk consumption (D) is recommended as excessive milk can hinder iron absorption.
A nurse is preparing to perform a dressing change on a 6-year-old child with mild cognitive impairment (CI) who sustained a minor burn. Which strategy should the nurse use to prepare the child for this procedure?
- A. Verbally explain what will be done
- B. Have the child watch a video on dressing change
- C. Demonstrate a dressing change on a doll
- D. Explain the importance of keeping the burn area clean
Correct Answer: C
Rationale: The correct answer is C: Demonstrate a dressing change on a doll. This strategy is most appropriate because children with cognitive impairment often benefit from visual aids and hands-on experiences. By demonstrating the dressing change on a doll, the nurse can provide a clear and concrete example for the child to understand what will happen during the procedure. This approach can help reduce anxiety and fear by making the process more tangible and relatable for the child.
Other choices are incorrect:
A: Verbally explaining may not be as effective for a child with cognitive impairment who may struggle to understand complex verbal instructions.
B: Watching a video may be overwhelming or confusing for the child with cognitive impairment.
D: Explaining the importance of keeping the burn area clean is important but may not adequately prepare the child for the procedure itself.
Which actions by the school nurse is important in the prevention of rheumatic fever?
- A. Encourage routine cholesterol screenings
- B. Conduct routine blood pressure screenings
- C. Refer children with sore throats for throat cultures
- D. Recommend aspirin instead of acetaminophen for minor discomforts
Correct Answer: C
Rationale: The correct answer is C: Refer children with sore throats for throat cultures. This is important in preventing rheumatic fever as it helps identify and treat streptococcal infections promptly, which can lead to rheumatic fever if left untreated. Encouraging routine cholesterol screenings (A) and conducting routine blood pressure screenings (B) are not directly related to preventing rheumatic fever. Recommending aspirin instead of acetaminophen (D) can actually be harmful in children with viral infections, increasing the risk of Reye's syndrome.