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A nurse is caring for a 1-year-old child who has been hospitalized. Which of the following items in the child's room is a common source of health care-associated infections?
- A. Disposable diapers
- B. Bedside commode
- C. Protective plastic gowns
- D. Unopened bottles of formula
Correct Answer: B
Rationale: The correct answer is B: Bedside commode. This item can harbor bacteria and pathogens if not properly cleaned and sanitized, leading to healthcare-associated infections. Disposable diapers (A) are single-use and unlikely to cause infections. Protective plastic gowns (C) are meant to prevent infections. Unopened bottles of formula (D) are sterile and not a common source of infections.
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A nurse is providing teaching to the guardian of an 11-month-old infant who has acute diarrhea. Which of the following food items should the nurse instruct the parent to provide to the infant?
- A. Children's tea
- B. Oral rehydration solution
- C. White grape juice
- D. Applesauce
Correct Answer: B
Rationale: The correct answer is B: Oral rehydration solution. This is the most appropriate choice because infants with acute diarrhea are at risk of dehydration due to fluid loss. Oral rehydration solution helps replace lost fluids and electrolytes, preventing dehydration. Children's tea (A) and white grape juice (C) are not recommended as they can worsen diarrhea due to their high sugar content. Applesauce (D) is also not suitable as it may be difficult for the infant to digest during diarrhea. It's important to prioritize rehydration in infants with diarrhea to prevent complications.
The nurse is continuing to care for the child. Select the 3 priority actions that the nurse should take.
- A. Review cast care instructions with the child's parents
- B. Administer ibuprofen 200 mg PO
- C. Place a nonadherent dressing on the right knee abrasion.
- D. Explain the cast application procedure to the child.
- E. Apply ice packs to the fingers and along the right forearm.
- F. Elevate the affected forearm with pillows.
Correct Answer: A,B,F
Rationale: The correct answers are A, B, and F. A) Reviewing cast care instructions with the child's parents ensures proper care at home. B) Administering ibuprofen helps manage pain and inflammation. F) Elevating the affected forearm reduces swelling. Choices C, D, and E are incorrect because C) placing a nonadherent dressing is not a priority over cast care, D) explaining cast application to the child is not essential for ongoing care, and E) applying ice packs to fingers and forearm is not as crucial as administering pain relief and elevating the affected area.
A nurse is caring for an infant who has necrotizing enterocolitis. Which of the following findings should the nurse expect?
- A. Hypertension
- B. Rounded abdomen
- C. Vomiting
- D. Tachypnea
Correct Answer: B,C,D
Rationale: The correct answer is B, C, and D. Necrotizing enterocolitis (NEC) in infants commonly presents with a rounded abdomen due to abdominal distension (B). Vomiting (C) is also a common symptom associated with NEC. Tachypnea (D) may occur due to abdominal distension and sepsis. Hypertension (A) is not typically associated with NEC in infants. The other choices are not provided, but based on typical NEC symptoms, they would not be expected in a patient with this condition.
A nurse is assessing a 2-year-old toddler. Which of the following findings should the nurse expect?
- A. Head circumference exceeds chest circumference
- B. Nontender, protruding abdomen
- C. Natural loss of deciduous teeth
- D. Palpable fontanels
Correct Answer: B
Rationale: The correct answer is B: Nontender, protruding abdomen. In toddlers, it is normal to have a nontender, protruding abdomen due to the physiological characteristics of their developing digestive system and musculature. This is because toddlers have less developed abdominal muscles and a larger liver in proportion to their body size, causing their abdomen to appear slightly distended. This finding is considered normal and does not typically indicate any underlying health issues. The other options are incorrect because: A: Head circumference exceeding chest circumference is not a typical finding in a 2-year-old toddler. C: Natural loss of deciduous teeth typically occurs around age 6-7, not in toddlers. D: Fontanels should be closed by 18 months, so palpable fontanels in a 2-year-old would be abnormal.
A nurse is caring for a client who has a history of depression and is experiencing a situational crisis. Which of the following actions should the nurse take first?
- A. Notify the client's support person.
- B. Teach the client relaxation techniques.
- C. Help the client identify personal strengths.
- D. Confirm the client's perception of the event.
Correct Answer: D
Rationale: The correct answer is D: Confirm the client's perception of the event. This is the first step because it helps the nurse understand the client's perspective, emotions, and triggers, which are crucial in crisis intervention. By confirming the client's perception, the nurse can establish rapport, validate the client's feelings, and assess the severity of the crisis. This information guides the nurse in developing an appropriate care plan and intervention strategies.
Choice A (Notify the client's support person) may be important but not the first step in crisis intervention. Choice B (Teach the client relaxation techniques) and C (Help the client identify personal strengths) are valuable interventions but should come after assessing the client's perception.