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A nurse in an emergency department is caring for a 3-year-old child who has suspected epiglottitis. Which of the following actions should the nurse take?
- A. Prepare to assist with intubation.
- B. Obtain a throat culture.
- C. Suction the child's oropharynx.
- D. Prepare a cool mist tent.
Correct Answer: A
Rationale: The correct answer is A: Prepare to assist with intubation. Epiglottitis is a medical emergency that can cause rapid airway obstruction. Intubation ensures a secure airway and oxygenation. Throat culture (B) is not a priority in this acute situation. Suctioning (C) can provoke spasm and worsen obstruction. Cool mist tent (D) does not address the immediate need for securing the airway.
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A nurse is planning postoperative care for an adolescent following scoliosis repair with spinal instrumentation. Which of the following actions should the nurse include in the plan of care?
- A. Maintain the head of the bed at a 30° angle.
- B. Offer sips of water due to having surgery.
- C. Log roll the adolescent every 2 hours.
- D. Assist the adolescent to ambulate 12 hours following surgery.
Correct Answer: C
Rationale: The correct answer is C: Log roll the adolescent every 2 hours. This is important to prevent pressure ulcers and maintain spinal alignment post-surgery. Log-rolling involves turning the patient as a unit to avoid twisting the spine. Maintaining the head of the bed at a 30° angle (choice A) is important for respiratory function but not specific to spinal surgery. Offering sips of water (choice B) is generally appropriate after surgery but not specific to spinal instrumentation. Assisting the adolescent to ambulate (choice D) should be done gradually and with caution, typically starting with sitting on the bedside first, rather than a fixed time frame like 12 hours post-surgery.
A nurse is assessing a child who has measles. Which of the following areas should the nurse inspect for Koplik spots?
Correct Answer: C
Rationale: The correct answer is C. Koplik spots are small, white, grain-like spots with a red halo that appear on the buccal mucosa opposite the molars. They are specific to measles and typically appear 2-4 days before the rash. Inspecting other areas like the skin (choice A), scalp (choice B), nails (choice D), ears (choice E), throat (choice F), or feet (choice G) would not reveal Koplik spots as they are only found in the mouth. Therefore, choice C is the correct option for assessing Koplik spots in a child with measles.
A nurse is planning care for a school-age child who is 4 hr postoperative following appendicitis. Which of the following actions should the nurse include in the plan of care?
- A. Apply a warm compress to the operative site once daily.
- B. Administer analgesics on a scheduled basis for the first 24 hr.
- C. Give cromolyn nebulized solution every 8 hr.
- D. Offer small amounts of clear liquids 6 hr following surgery.
Correct Answer: B
Rationale: The correct answer is B: Administer analgesics on a scheduled basis for the first 24 hr.
Rationale: Postoperative pain management is crucial for the comfort and recovery of the child. Administering analgesics on a scheduled basis helps control pain effectively and prevents breakthrough pain. The first 24 hours following surgery are critical for pain control as the child may experience increased discomfort during this time. By providing analgesics on a schedule, the nurse ensures that the child receives timely pain relief.
Summary of incorrect choices:
A: Applying a warm compress to the operative site is not a standard practice post-appendectomy and may not effectively manage pain.
C: Cromolyn nebulized solution is not typically used for pain management post-appendectomy.
D: Offering clear liquids 6 hours following surgery may not be appropriate as the child may not be ready to tolerate oral intake so soon after surgery.
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 teaching a group of school-age children about healthy snack options. Which of the following snacks should the nurse include?
- A. Cheesecake
- B. Air-popped popcorn
- C. Milkshake made with whole milk
- D. Baked potato chips
Correct Answer: B
Rationale: The correct answer is B: Air-popped popcorn. It is a healthy snack option for school-age children because it is low in calories and high in fiber, making it a satisfying and nutritious choice. Popcorn is a whole grain snack that provides essential nutrients like fiber and antioxidants. It is a good alternative to sugary or high-fat snacks. Cheesecake (A) is high in sugar and saturated fat, not a healthy choice. Milkshake made with whole milk (C) is high in calories, sugar, and saturated fat. Baked potato chips (D) may be lower in fat than regular chips but are still high in calories and lack the fiber content of popcorn.