Nokea
A nurse is caring for a preschooler who has epiglottitis from a streptococcal infection. Which of the following actions should the nurse take?
- A. Attempt to obtain a throat culture.
- B. Use a tongue depressor to observe the back of the throat.
- C. Apply humidified oxygen via a mask.
- D. Initiate airborne precautions.
Correct Answer: C
Rationale: This helps to keep the airways moist and can provide some relief and improve oxygenation.
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A nurse is caring for a child following an open reduction and internal fixation of a fractured femur and application of a cast. The cast has a window cut in it for viewing of the incision. Which of the following actions should the nurse take first?
- A. Remove the window and view the incision.
- B. Medicate the client for pain.
- C. Perform neurovascular checks of the affected extremity.
- D. Turn the client so the cast will dry on all sides.
Correct Answer: C
Rationale: Performing neurovascular checks is the highest priority to ensure that circulation sensation and movement are intact.
A nurse is caring for a school-age child who has a fracture to the right femur. Which of the following findings is the nurse's priority?
- A. Capillary refill less than 2 seconds
- B. Tingling in the right foot
- C. 2+ right pedal pulse
- D. Respiratory rate 24/min
Correct Answer: B
Rationale: Tingling (paraesthesia) can be a sign of nerve damage or compromised circulation which may indicate complications such as compartment syndrome. This is a priority finding because it can lead to severe consequences if not addressed promptly.
A nurse on a medical-surgical unit is caring for a group of children. Which of the following findings should alert the nurse that one of the children is a potential victim of abuse?
- A. A school-age child who cries when the nurse is giving him an injection
- B. A toddler who has multiple bruises on the shins of both legs and his parents report that he is clumsy
- C. A preschooler who has a BMI indicating obesity
- D. An adolescent who asks to stay in the hospital because he likes the room
Correct Answer: D
Rationale: This might indicate that the adolescent is not feeling safe or comfortable at home which could be a sign of abuse or neglect.
A nurse is reinforcing teaching about immunizations with the parents of a newborn. Which of the following statements should the nurse make?
- A. Your newborn will receive the first DTaP vaccine during the initial well-baby visit.
- B. Your newborn should receive an immunization for MMR at 6 months.
- C. Your newborn is scheduled to have a hepatitis B vaccine prior to discharge.
- D. Your newborn should receive the PCV vaccine two times prior to his first birthday.
Correct Answer: C
Rationale: Hepatitis B vaccine is recommended to be given within 24 hours of birth as the first dose of a series.
A nurse is caring for a toddler who had a cast applied 2 hr ago due to multiple fractures of the right hand. Which of the following findings should the nurse report immediately to the charge nurse?
- A. The parent reports the child will not keep the arm elevated on the pillow.
- B. The fingers on the right hand have a capillary refill of 4 seconds.
- C. The fingertips of the right hand are swollen and bruised.
- D. The child is not attempting to move her right arm or fingers.
Correct Answer: B
Rationale: A capillary refill time of more than 2 seconds indicates poor perfusion which can be a sign of compartment syndrome.