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An infant who has respiratory syncytial virus (RSV)
A nurse is assisting with the admission of an infant who has respiratory syncytial virus (RSV), which of the following rooms should the nurse assign the infant?
- A. A room with a toddler who has pneumonia
- B. A private room with reverse isolation
- C. A private room with contact/droplet precautions
- D. A room with an infant who has croup
Correct Answer: C
Rationale: The correct answer is C: A private room with contact/droplet precautions. RSV is spread through respiratory secretions, so contact/droplet precautions are necessary to prevent transmission. Assigning the infant to a private room minimizes exposure to others. Choice A is incorrect as it puts the infant at risk of acquiring pneumonia. Choice B, reverse isolation, is not needed for RSV. Choice D, room with an infant with croup, is incorrect as both infants could potentially spread their respective infections to each other.
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A 9-year-old child for an IV catheter insertion
A nurse is preparing a 9-year-old child for an IV catheter insertion. Which of the following actions should the nurse take first?
- A. Allow the child to see and touch IV tubing and supplies.
- B. Explain to the child's parents what role they will have during the procedure.
- C. Describe the procedure using visual aids.
- D. Ask the child what he knows about the procedure.
Correct Answer: D
Rationale: The correct answer is D, asking the child what he knows about the procedure first. This step is crucial as it helps assess the child's understanding, address any misinformation, and tailor the explanation to the child's knowledge level. It also promotes trust and cooperation. Option A may increase anxiety as seeing the supplies without understanding can be intimidating. Option B involves parents before addressing the child directly. Option C may overwhelm the child with too much information at once.
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.
A toddler receiving ear drops
While administering ear drops to a toddler, a nurse by pulls the auricle down and back. The mother asks, 'Why are you pulling the ear that way?' Which of the following responses should the nurse make?
- A. When I use this technique the medication will not run out of the ear.
- B. This opens the ear canal, allowing medication to reach the inner ear region.
- C. This is the safest and easiest way to administer this medication.
- D. When I use the technique, your child experiences less pain.
Correct Answer: B
Rationale: The correct answer is B: This opens the ear canal, allowing medication to reach the inner ear region. By pulling the auricle down and back, the nurse straightens the ear canal in toddlers, making it easier for the ear drops to reach the inner ear where they are most effective. This technique helps ensure that the medication is properly administered and absorbed.
Incorrect Answers:
A: When I use this technique the medication will not run out of the ear - This is incorrect because the aim of pulling the ear is not to prevent medication from running out but to facilitate its entry.
C: This is the safest and easiest way to administer this medication - This is incorrect as the safety and ease of administration are not the primary reasons for pulling the ear in this context.
D: When I use the technique, your child experiences less pain - This is incorrect as the main purpose of pulling the ear is not to reduce pain but to ensure effective delivery of the medication to the inner ear.
An 8-month-old child who starts to cry when his parents leave
A nurse is caring for an 8-month-old child who starts to cry when his parents leave. The nurse should make which of the following statements to the parents?
- A. At this age you should expect your child to be upset when you leave.
- B. Your child needs to rest.
- C. will notify the provider of his behavior.
- D. Your child is responding to an overstimulating environment.
Correct Answer: A
Rationale: Correct Answer: A
Rationale: At 8 months old, infants develop separation anxiety, causing distress when parents leave. Acknowledging this is crucial for parents to understand normal child development. Choice B is irrelevant as the child's emotional needs should be addressed, not just physical rest. Choice C is unnecessary unless the behavior persists or causes concern. Choice D is incorrect as the child's crying is likely due to separation anxiety, not overstimulation.
A school-age child who has cystic fibrosis
A nurse is reinforcing teaching with the parents of a school-age child who has cystic fibrosis. Which of the following statements should the nurse make?
- A. Your child's diet should be high in carbohydrates & proteins with no restriction of fats.
- B. Limit your child's intake of sodium to avoid complications.
- C. A pigeon-shaped chest might become evident as the disease progresses.
- D. Administer a bronchodilator to the child after chest percussion therapy.
Correct Answer: C
Rationale: The correct answer is C: A pigeon-shaped chest might become evident as the disease progresses. In cystic fibrosis, the chest may appear pigeon-shaped due to the abnormal growth of the ribs and sternum. This is caused by chronic respiratory issues and increased work of breathing. It is important for the nurse to educate the parents about this potential physical manifestation of the disease so they can monitor their child's condition closely.
Incorrect choices:
A: Your child's diet should be high in carbohydrates & proteins with no restriction of fats - This is incorrect as children with cystic fibrosis often require a high-calorie, high-fat diet to meet their increased energy needs.
B: Limit your child's intake of sodium to avoid complications - While monitoring sodium intake can be important for some conditions, it is not a primary concern in cystic fibrosis.
D: Administer a bronchodilator to the child after chest percussion therapy - While bronchodilators may be used in cystic fib