Nokea
A child who is to receive percussion, vibration, and postural drainage
A nurse is caring for a child who is to receive percussion, vibration, and postural drainage. Which of the following actions should the nurse take first?
- A. Instruct the client to cough
- B. Perform vibration while the client exhales slowly through the nose.
- C. Percuss the upper posterior chest.
- D. Administer albuterol by nebulizer.
Correct Answer: D
Rationale: The correct answer is D: Administer albuterol by nebulizer. This should be done first to help open up the airways and facilitate the effectiveness of the subsequent treatments. Albuterol is a bronchodilator that helps to relax the muscles in the airways, making it easier for the child to breathe. Administering albuterol before percussion, vibration, and postural drainage will help optimize the child's lung function and overall response to the respiratory therapy.
Choice A: Instruct the client to cough - This can be done after administering albuterol to help clear any loosened secretions.
Choice B: Perform vibration while the client exhales slowly through the nose - This can be done after administering albuterol to further aid in loosening and mobilizing secretions.
Choice C: Percuss the upper posterior chest - This can be done after administering albuterol to assist in clearing secretions from the lungs.
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A child who has cystic fibrosis
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 restrict the amount of salt in my child's meals.
- B. I will put my child in daycare to ensure that she socializes with other children.
- C. I will make sure my child washes her hands before eating.
- D. I will provide low-fat meals for my child.
Correct Answer: C
Rationale: The correct answer is C: "I will make sure my child washes her hands before eating." This statement indicates an understanding of the teaching because proper handwashing is crucial in preventing infections in individuals with cystic fibrosis who are more susceptible to respiratory infections. By washing hands before eating, the child can reduce the risk of exposure to harmful pathogens.
Choice A is incorrect because restricting salt intake is not a priority in managing cystic fibrosis. Choice B is incorrect as the focus should be on hygiene and health rather than socialization. Choice D is incorrect as children with cystic fibrosis actually require a higher calorie and fat intake.
An infant
A nurse is collecting data from an infant. Which of the following sites is the most reliable location to check the infant's pulse?
- A. Apical
- B. Dorsalis pedis
- C. Temporal
- D. Carotid
Correct Answer: A
Rationale: The correct answer is A: Apical. The apical pulse, located at the apex of the heart, is the most reliable site to check an infant's pulse. It accurately reflects the heart rate and rhythm due to its proximity to the heart. The other choices are less reliable for infants: B (Dorsalis pedis) and C (Temporal) may be difficult to locate accurately on infants, D (Carotid) is not recommended for routine pulse checks in infants due to the risk of pressing too firmly on the delicate neck structures.
A newborn who has a myelomeningocele and is admitted to the newborn intensive care unit (NICU) to await surgery
A nurse is caring for a newborn who has a myelomeningocele and is admitted to the newborn intensive care unit (NICU) to await surgery. Which of the following nursing goals is priority in the care of this infant?
- A. Promote maternal-infant bonding
- B. Provide age-appropriate stimulation.
- C. Educate the parents about the defect.
- D. Maintain integrity of the sac.
Correct Answer: D
Rationale: The correct answer is D: Maintain integrity of the sac. This is the priority goal because the newborn with myelomeningocele is at risk for infection and further damage if the sac is not properly cared for. By ensuring the sac is clean, covered, and protected, the nurse can help prevent complications such as meningitis. Promoting maternal-infant bonding (A) is important but not the priority at this time. Providing age-appropriate stimulation (B) is not as urgent as ensuring the sac's integrity. Educating the parents about the defect (C) is crucial for long-term care but not the immediate priority.
An adolescent who is having a sickle cell crisis
A nurse is caring for an adolescent who is having a sickle cell crisis. Which of the following nursing actions should the nurse take?
- A. withhold opioids to avoid dependence
- B. Assist RN with administering a blood transfusion
- C. Initiate a 2 L/day fluid restriction
- D. Encourage exercise
Correct Answer: B
Rationale: The correct answer is B: Assist RN with administering a blood transfusion. During a sickle cell crisis, blood transfusions can help improve oxygen delivery to tissues by increasing the number of normal red blood cells. This can help alleviate symptoms and prevent complications. Withholding opioids (choice A) can lead to inadequate pain management. Initiation of fluid restriction (choice C) is inappropriate as hydration is crucial during a sickle cell crisis. Encouraging exercise (choice D) can worsen the crisis by increasing the risk of vaso-occlusive events.
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.