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A home health nurse is teaching a new parent about caring for his 1-week-old infant. Which of the following statements by the client indicates an understanding of the teaching?
- A. I will avoid picking up my baby too often to keep from spoiling him.
- B. I will hang a pastel-colored mobile 24 inches above my baby's crib.
- C. I can use a firm pillow to prop up the bottle when feeding my baby.
- D. I will place a ticking clock nearby to soothe my baby throughout the day.
Correct Answer: B
Rationale: The correct answer is B: "I will hang a pastel-colored mobile 24 inches above my baby's crib." This statement indicates an understanding of the teaching because hanging a mobile can provide visual stimulation for the infant, promoting cognitive development. It also helps in soothing and calming the baby.
Incorrect choices:
A: Incorrect because picking up the baby frequently is not spoiling and is important for bonding and meeting the baby's needs.
C: Incorrect because using a firm pillow to prop up the bottle can be a choking hazard and is not recommended for feeding infants.
D: Incorrect because placing a ticking clock nearby can actually be a suffocation risk and is not recommended for soothing babies.
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A nurse is preparing to administer immunizations to a 5-year-old child who is up to date with the current immunization schedule. Which of the following immunizations should the nurse plan to administer?
- A. Haemophilus influenzae type B
- B. Varicella
- C. Hepatitis B
- D. Diphtheria
Correct Answer: B
Rationale: The correct answer is B: Varicella. At the age of 5, children are due for their second dose of the Varicella vaccine according to the current immunization schedule. Varicella vaccine is given to protect against chickenpox. Haemophilus influenzae type B and Hepatitis B vaccines are typically administered at earlier ages. Diphtheria vaccine is usually given in combination with other vaccines and not as a standalone. In summary, Varicella is the correct choice as it aligns with the child's age and the recommended immunization schedule, while the other options are not due at this time.
A nurse is preparing to admit a 6-year-old with varicella to the pediatric unit. Which of the following actions should the nurse take?
- A. Assign the child to a negative air pressure room.
- B. Administer aspirin to the child for fever.
- C. Use droplet precautions when caring for the child.
- D. Assess the child for Koplik spots.
Correct Answer: A
Rationale: The correct answer is A: Assign the child to a negative air pressure room. Varicella, commonly known as chickenpox, is highly contagious and spreads through respiratory droplets. Placing the child in a negative air pressure room helps prevent the spread of the virus to others by containing the infectious particles within the room. This isolation measure is crucial in protecting both the child and other patients.
Choice B is incorrect because aspirin should not be administered to children with varicella due to the risk of Reye's syndrome. Choice C is incorrect as droplet precautions are not necessary for varicella, which primarily spreads through airborne respiratory droplets. Choice D is incorrect as Koplik spots are associated with measles, not varicella.
A nurse on a pediatric unit is caring for four children. The nurse should use droplet precautions for which of the following children?
- A. A school-age child who has viral conjunctivitis
- B. A preschool-age child who has pediculosis capitis
- C. A toddler who has seasonal influenza
- D. An adolescent who has hepatitis A
Correct Answer: C
Rationale: The correct answer is C: A toddler who has seasonal influenza. Droplet precautions are required for diseases transmitted via respiratory droplets, such as influenza. Seasonal influenza is highly contagious through respiratory secretions, making it crucial to prevent transmission. The other choices do not require droplet precautions: A - viral conjunctivitis is spread through direct contact with eye secretions, B - pediculosis capitis (head lice) is spread through direct head-to-head contact, and D - hepatitis A is primarily spread through the fecal-oral route. Therefore, C is the correct choice for droplet precautions.
A nurse is providing teaching about home safety to the adult child of an older adult client who is postoperative following knee replacement surgery. Which of the following instructions should the nurse include?
- A. Encourage the client to avoid wearing shoes at home.
- B. Ensure that area rugs have rubber backs.
- C. Mark the edges of the doorway to the house with tape.
- D. Place a throw rug over electrical cords.
Correct Answer: B
Rationale: The correct answer is B: Ensure that area rugs have rubber backs. This instruction is important to prevent slips and falls, especially for an older adult recovering from knee replacement surgery. Rubber-backed rugs provide traction and stability, reducing the risk of accidents. Encouraging the client to avoid wearing shoes at home (A) may increase the risk of slipping on smooth surfaces. Marking the edges of the doorway with tape (C) may not be effective and could create a tripping hazard. Placing a throw rug over electrical cords (D) is unsafe as it can cause the older adult to trip.
A nurse is caring for a group of toddlers receiving digoxin therapy. For which of the following clients should the nurse plan to hold the dose of digoxin?
- A. A toddler who has an apical pulse of 100 bpm
- B. A toddler who has a potassium level of 4.0 mEq/L (3.6 to 5.2 mEq/L)
- C. A toddler who has a digoxin level of 1.2 ng/mL (0.8 to 2.0 ng/mL)
- D. A toddler who has vomited 2 times in the last hour
Correct Answer: D
Rationale: The correct answer is D because vomiting can lead to decreased absorption of digoxin, potentially resulting in subtherapeutic levels. Holding the dose in this situation prevents giving an ineffective dose. Option A is incorrect because an apical pulse of 100 bpm is within the normal range for toddlers on digoxin. Option B is incorrect because a potassium level of 4.0 mEq/L is also within the normal range. Option C is incorrect because a digoxin level of 1.2 ng/mL falls within the therapeutic range.