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A nurse is planning care for a child during admission to the facility. Which of the following actions should the nurse take first?
- A. Obtain a prescription for pain medication.
- B. Collect blood cultures.
- C. Transport the child to obtain a CT scan.
- D. Initiate seizure precautions.
Correct Answer: D
Rationale: The correct answer is D: Initiate seizure precautions. This should be the first action as it prioritizes the safety of the child. Seizure precautions involve ensuring a safe environment, such as removing any potential hazards and providing padding to prevent injury during a seizure. Collecting blood cultures (B) and obtaining a prescription for pain medication (A) can be important but are not as urgent as ensuring the child's safety in case of a seizure. Transporting the child for a CT scan (C) is not an immediate priority unless there is a critical need.
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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 providing teaching to a parent of a child who has HIV. Which of the following statements by the parent indicates an understanding of the teaching?
- A. The risk of transmission decreases once my child is on zidovudine for 2 weeks
- B. My child will need to double his medications for the next 6 months.
- C. My child will need to repeat his childhood immunizations once he's in remission.
- D. I will ensure that my child is tested for tuberculosis every year.
Correct Answer: D
Rationale: The correct answer is D because regular testing for tuberculosis is crucial for individuals with HIV due to their increased risk of developing tuberculosis. This indicates the parent understands the importance of monitoring for potential complications. Choice A is incorrect because zidovudine does not impact transmission risk. Choice B is incorrect as doubling medications without healthcare provider guidance can be harmful. Choice C is incorrect as childhood immunizations are typically not repeated in remission.
The nurse is continuing to care for the child. Complete the following sentence by using the list of options. The child is at highest risk of developing------ as evidenced bt the child's------
- A. Deep vein thrombosis
- B. Osteomyelitis
- C. Compartment syndrome
- D. Swelling
- E. Warmth and redness
- F. Paresthesia
- G. Weak pulses
Correct Answer: C,F
Rationale: The correct answer is C, Compartment syndrome, and F, Paresthesia. Compartment syndrome results from increased pressure within a closed anatomical space, leading to compromised blood flow and nerve function. Paresthesia, abnormal sensations like tingling or numbness, is an early sign of nerve compression in compartment syndrome. The combination of these symptoms indicates a critical condition requiring immediate intervention to prevent tissue damage. Choices A, B, D, and E do not align with the clinical presentation of compartment syndrome, whereas choice G, weak pulses, may be seen in severe cases but are not specific enough to be the highest risk factor in this scenario.
A nurse is caring for an adolescent client who has cystic fibrosis. Which of the following actions should the nurse instruct the client to take prior to initiating postural drainage?
- A. Take pancrelipase.
- B. Complete oral hygiene.
- C. Eat a meal.
- D. Use an albuterol inhaler.
Correct Answer: D
Rationale: The correct answer is D: Use an albuterol inhaler. Prior to postural drainage, the client with cystic fibrosis should use an albuterol inhaler to help open up the airways and facilitate effective mucus clearance during the procedure. Albuterol is a bronchodilator that helps to relax the muscles in the airways, making it easier to breathe and improving the effectiveness of postural drainage. Pancrelipase (choice A) is taken with meals to aid in digestion, so it is not necessary before postural drainage. Completing oral hygiene (choice B) is important but not directly related to postural drainage. Eating a meal (choice C) may lead to discomfort during the procedure. The priority is to ensure clear airways with the use of the albuterol inhaler.
A nurse is caring for a client in the outpatient health clinic. For each potential nursing Intervention, click to specify if the intervention is indicated or not indicated.
- A. Encourage naps during the day when client is tired.
- B. Encourage a regular sleep-wake schedule.
- C. Encourage high-calorie finger foods.
- D. Advise client to notify provider if pregnant.
- E. Instruct client to avoid foods that have been fermented or aged.
- F. Advise client to rise slowly from sitting position.
- G. Encourage client to sleep until later in the morning.
Correct Answer:
Rationale: Correct Answer:
Rationale:
- Encouraging naps during the day when the client is tired is indicated for managing fatigue.
- Encouraging a regular sleep-wake schedule helps promote better sleep hygiene.
- Advising the client to notify the provider if pregnant is crucial for appropriate prenatal care.
- Other options are not indicated: high-calorie finger foods may not be suitable for all clients, avoiding fermented or aged foods is specific dietary advice, rising slowly is for orthostatic hypotension, and sleeping until later in the morning may disrupt the sleep-wake cycle.