Nokea
A nurse is caring for a 2-month-old infant who is postoperative following repair of a cleft lip and palate. The surgeon prescribes restraints. The nurse should apply which of the following types of restraints to the infant?
- A. Wrist
- B. Mummy
- C. Elbow
- D. Jacket
Correct Answer: C
Rationale: Elbow restraints prevent the infant from bending their arms keeping them from touching their face and disrupting the surgical site.
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A nurse is planning care for a 4-year-old child who has been admitted to the hospital. Which of the following toys should the nurse plan to provide the child?
- A. Modeling clay
- B. Brightly-colored mobile
- C. 100-piece jigsaw puzzle
- D. Checkerboard and checkers
Correct Answer: A
Rationale: Modeling clay is appropriate for a 4-year-old helping with fine motor skills and creativity.
A nurse is reinforcing teaching with an assistive personnel (AP) about counting the respiratory rate for a 1-month-old infant. Which of the following statements by the AP indicates an understanding of the teaching?
- A. I will immediately report irregular respirations.
- B. I will immediately report a respiratory rate of 28.
- C. I will count the baby's respirations for 30 seconds and multiply by two.
- D. I will count the baby's respirations by observing abdominal movements.
Correct Answer: D
Rationale: In infants respiration is primarily diaphragmatic making abdominal movements a reliable indicator of respiratory rate.
A nurse is assisting with the admission of a child who has pertussis. Which of the following actions should the nurse take?
- A. Initiate droplet precautions.
- B. Initiate a protective environment.
- C. Initiate contact precautions.
- D. Initiate airborne precautions.
Correct Answer: A
Rationale: Pertussis (whooping cough) is transmitted via respiratory droplets.
A nurse is collecting data from a 4-year-old child. Which of the following findings should the nurse expect?"
- A. Heart rate 110/min
- B. Capillary refill greater than 3 seconds
- C. Weight gain of 0.9 kg (2 lb) in a year
- D. Respiratory rate 32/min
Correct Answer: A
Rationale: A heart rate of 110 beats per minute is within the normal range for a 4-year-old child. The typical heart rate for this age is between 80 to 120 beats per minute.
A nurse is reinforcing discharge instructions with a parent of a child who has cystic fibrosis. Which of the following statements by the parent Indicates an understanding of the teaching?
- A. I will provide low-fat meals for my child.
- B. I will restrict the amount of salt in my child's meals.
- C. I will put my child in daycare to ensure that she socializes with other children.
- D. I will make sure my child washes her hands before eating.
Correct Answer: D
Rationale: Hand hygiene is crucial for preventing infections which are a significant risk for children with cystic fibrosis.