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A toddler who is scheduled to have a lumbar puncture
A nurse is caring for a toddler who is scheduled to have a lumbar puncture. Which of the following actions should the nurse take?
- A. Restrain the toddler for 1 hr after the procedure.
- B. Swaddle the toddler in a warm blanket.
- C. Ask another nurse to assist with holding the toddler in a prone position.
- D. Place the toddler in a side-lying knee-chest position
Correct Answer: D
Rationale: The correct answer is D: Place the toddler in a side-lying knee-chest position. This position helps to open up the spaces between the vertebrae, making it easier for the healthcare provider to perform the lumbar puncture. Restraint is not recommended as it can cause distress and increase the risk of complications. Swaddling in a warm blanket may not provide the necessary positioning for the procedure. Asking another nurse to assist with holding the toddler in a prone position may not be as effective in achieving the optimal positioning needed for a lumbar puncture.
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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 14-month-old toddler who is 24 hr following interventions
A nurse is contributing to the plan of care of a 14-month-old toddler who is 24 h following interventions should the nurse include in the plan?
- A. Give the toddler a hard-tipped sippy cup to drink liquid
- B. Suction the toddler nose and mouth every hour
- C. Maintain elbow restraint
- D. Provide soft foods for the toddler
Correct Answer: D
Rationale: The correct answer is D: Provide soft foods for the toddler. At 14 months, toddlers should be transitioning to a diet of soft foods to aid in their development and prevent choking hazards. Hard-tipped sippy cups (choice A) are not recommended as they can pose a risk of injury. Suctioning the toddler's nose and mouth every hour (choice B) is excessive and can lead to irritation and discomfort. Maintaining elbow restraint (choice C) is unnecessary and may hinder the toddler's mobility and development. In summary, providing soft foods aligns with the toddler's age and promotes safe and appropriate feeding practices.
A child who has suspected cystic fibrosis
A nurse is reinforcing teaching about diagnostic tests with the parents of a child who has suspected cystic fibrosis. Which of the following diagnostic tests should the nurse include as the most definitive when diagnosing cystic fibrosis?
- A. Pulmonary function test
- B. Sweat chloride test
- C. Stool fat content analysis
- D. Sputum culture
Correct Answer: B
Rationale: The correct answer is B: Sweat chloride test. This test is the most definitive diagnostic tool for cystic fibrosis as it measures the concentration of chloride in sweat, which is typically elevated in individuals with the condition. The other choices are not as specific to cystic fibrosis. A pulmonary function test (A) evaluates lung function but does not specifically diagnose cystic fibrosis. Stool fat content analysis (C) is used to assess fat malabsorption but does not confirm cystic fibrosis. Sputum culture (D) is used to identify respiratory infections but is not specific to cystic fibrosis.
An infant who has respiratory syncytial virus (RSV)
A nurse is assisting with the admission of an infant who has respiratory syncytial virus (RSV), which of the following rooms should the nurse assign the infant?
- A. A room with a toddler who has pneumonia
- B. A private room with reverse isolation
- C. A private room with contact/droplet precautions
- D. A room with an infant who has croup
Correct Answer: C
Rationale: The correct answer is C: A private room with contact/droplet precautions. RSV is spread through respiratory secretions, so contact/droplet precautions are necessary to prevent transmission. Assigning the infant to a private room minimizes exposure to others. Choice A is incorrect as it puts the infant at risk of acquiring pneumonia. Choice B, reverse isolation, is not needed for RSV. Choice D, room with an infant with croup, is incorrect as both infants could potentially spread their respective infections to each other.