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A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take?
- A. Perform the procedure prior to meals.
- B. Hold hand flat to perform percussions on the child.
- C. Administer a bronchodilator after the procedure.
- D. Perform the procedure twice each day.
Correct Answer: A
Rationale: The correct answer is A. Performing postural drainage prior to meals helps prevent aspiration of food or stomach contents during the procedure. Postural drainage is typically done 1-2 hours after meals to minimize the risk of aspiration. Holding the hand flat (B) is incorrect as cupped hands are used for percussion to avoid injury. Administering a bronchodilator after (C) can lead to increased mucous production. Performing the procedure twice daily (D) is generally recommended, but the timing in relation to meals is crucial.
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A nurse is caring for an infant who has diaper dermatitis. Which of the following actions should the nurse take?
- A. Apply talcum powder to the irritated area.
- B. Wipe stool from the skin using store-bought baby wipes.
- C. Apply zinc oxide ointment to the irritated area.
- D. Wipe urine from the skin using a cool cloth.
Correct Answer: C
Rationale: The correct answer is C: Apply zinc oxide ointment to the irritated area. Zinc oxide ointment provides a protective barrier on the skin, helping to soothe and heal diaper dermatitis. It also helps to keep moisture away from the irritated skin, promoting healing.
Incorrect options:
A: Applying talcum powder can further irritate the skin as it can be abrasive.
B: Store-bought baby wipes may contain chemicals or fragrances that can worsen the condition.
D: Wiping urine with a cool cloth is a good practice, but it does not address the issue of diaper dermatitis.
Overall, option C is the best choice as it directly addresses the diaper dermatitis by providing a protective barrier and promoting healing.
A nurse is planning care for a toddler who has epiglottitis. Which of the following interventions should the nurse include?
- A. Offer a high-calorie, high-protein diet.
- B. Administer pancreatic enzymes with meals.
- C. Initiate droplet precautions.
- D. Carefully suction the child's oropharynx to remove secretions.
Correct Answer: C
Rationale: The correct answer is C: Initiate droplet precautions. Epiglottitis is a serious condition that involves inflammation of the epiglottis, which can lead to airway obstruction. Droplet precautions are necessary to prevent the spread of infection, as epiglottitis is usually caused by a bacterial infection. Offering a high-calorie, high-protein diet (choice A) is not the priority in the acute phase of epiglottitis. Administering pancreatic enzymes with meals (choice B) is unrelated to the care of a toddler with epiglottitis. Carefully suctioning the child's oropharynx to remove secretions (choice D) can potentially worsen the condition by triggering a gag reflex and causing further airway obstruction.
A nurse is providing teaching about the administration of gastrostomy tube feedings to the parents of a school-age child. Which of the following instructions should the nurse include?
- A. Administer the feeding over 30 min.
- B. Change the feeding bag and tubing every 3 days.
- C. Place the child in a supine position after the feeding.
- D. Warm the formula in the microwave prior to administration.
Correct Answer: A
Rationale: The correct answer is A: Administer the feeding over 30 min. This instruction is important to prevent complications such as aspiration and dumping syndrome. Administering the feeding slowly over 30 minutes allows for proper digestion and absorption. Choice B is incorrect because feeding bags and tubing should be changed every 24 hours to prevent bacterial growth. Choice C is incorrect because the child should be placed in an upright position, not supine, after the feeding to reduce the risk of aspiration. Choice D is incorrect because warming formula in the microwave can create hot spots and lead to burns.
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 in the emergency department is caring for a 10-year-old child. The nurse is assessing the child. Which of the following findings require follow-up? Select the 5 findings that require follow-up.
- A. Temperature
- B. Heart rate
- C. Report of pain
- D. Respiratory rate
- E. Tonsillar findings
- F. Oxygen saturation
Correct Answer: A,B,C,D,E,F
Rationale: The correct answer includes all options (A, B, C, D, E, F) because they are essential vital signs and key indicators of the child's health status. Temperature (A), heart rate (B), respiratory rate (D), and oxygen saturation (F) are crucial physiological parameters that can indicate underlying health issues if abnormal. Report of pain (C) is important to assess the child's comfort and potential underlying conditions. Tonsillar findings (E) could indicate infections or other throat issues. Follow-up on all these findings is necessary for a comprehensive assessment of the child's health.