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A child who has epiglottitis
A nurse is planning care for a child who has epiglottitis. Which of the following actions should the nurse plan to take?
- A. Obtain a throat culture.
- B. Visualize the epiglottis using a tongue depressor.
- C. Provide moist air to reduce the inflammation of the epiglottis
- D. Initiate airborne precautions.
Correct Answer: C
Rationale: The correct answer is C: Provide moist air to reduce the inflammation of the epiglottis. In epiglottitis, the epiglottis is inflamed and can obstruct the airway, leading to respiratory distress. Providing moist air can help reduce inflammation and ease breathing. Option A, obtaining a throat culture, is not a priority in the acute management of epiglottitis. Option B, visualizing the epiglottis using a tongue depressor, can be dangerous and is contraindicated due to the risk of further aggravating the condition. Option D, initiating airborne precautions, is not necessary as epiglottitis is not spread through the air. Therefore, option C is the most appropriate action to prioritize in the care of a child with epiglottitis.
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An infant who has spina bifida
A nurse is caring for an infant who has spina bifida. Which of the following actions should the nurse take?
- A. Place the infant in prone position.
- B. Cover the infant's lesion with a dry cloth.
- C. Feed the infant through an NG tube.
- D. Diapering over a low defect will keep the infant free from infection
Correct Answer: D
Rationale: The correct answer is D. Diapering over a low defect will keep the infant free from infection. This is because keeping the area covered with a diaper helps prevent contamination and infection. Placing the infant in prone position (choice A) is not recommended as it can put pressure on the lesion. Covering the lesion with a dry cloth (choice B) may not provide adequate protection from contamination. Feeding the infant through an NG tube (choice C) is not directly related to preventing infection at the lesion site. Therefore, the best option is to diaper over the defect to maintain hygiene and prevent infection.
An 8-year-old child who has sickle cell anemia and is recovering from a vaso-occlusive crisis
A nurse is caring for an 8-year-old child who has sickle cell anemia and is recovering from a vaso-occlusive crisis. Which of the following precautions should the nurse include in the discharge teaching?
- A. Drink eight glass of fluid daily.
- B. Maintain an updated hemophilus influence type b immunisation
- C. Avoid playground activities at school
- D. Assume postural drainage positions every 6 hrs
Correct Answer: A
Rationale: The correct answer is A: Drink eight glasses of fluid daily. This is crucial for children with sickle cell anemia to prevent dehydration, which can trigger vaso-occlusive crises. Adequate hydration helps maintain blood flow and prevent sickling of red blood cells. Maintaining an updated hemophilus influenzae type b immunization (choice B) is important for preventing infections but is not directly related to vaso-occlusive crises. Avoiding playground activities at school (choice C) is unnecessary as long as the child is careful and stays hydrated. Assuming postural drainage positions every 6 hours (choice D) is not relevant for sickle cell anemia management.
A 4-year-old child who is 2 days postoperative following the insertion of a ventriculoperitoneal shunt
A nurse is caring for a 4-year-old child who is 2 days postoperative following the insertion of a ventriculoperitoneal shunt. Which of the following findings should the nurse identify as the priority?
- A. Lethargy
- B. Urine output 70 mL in 2 hr
- C. Lying flat on the unaffected side
- D. Respiratory rate 20/min
Correct Answer: A
Rationale: The correct answer is A: Lethargy. Following a ventriculoperitoneal shunt insertion, lethargy in a child could indicate increased intracranial pressure, a potentially life-threatening complication. The priority is to assess for signs of neurological deterioration promptly. Urine output (B) is important but not as urgent as assessing neurological status. Lying flat on the unaffected side (C) is not a priority; positioning can be adjusted later. Respiratory rate (D) within normal range is reassuring but not the priority in this case.
An 8-month-old infant who will be admitted for surgery
A nurse is reinforcing teaching with the parents of an 8-month-old infant who will be admitted for surgery. Which of the following instructions should the nurse include in the teaching?
- A. You should begin to manipulate the infant's bedtime based on the hospitals visiting hours.
- B. You should bring the infant's favorite blanket to the hospital
- C. You should read the child a story about hospitalization.
- D. You will need to go home when it is not visiting hours.
Correct Answer: B,C
Rationale: The correct answer is B and C. Bringing the infant's favorite blanket to the hospital (B) provides comfort and familiarity in an unfamiliar environment, reducing anxiety. Reading the child a story about hospitalization (C) can help prepare the child for the upcoming experience, easing fears.
Choice A is incorrect because manipulating bedtime based on visiting hours disrupts the infant's routine. Choice D is incorrect as parents are usually allowed to stay with their child in the hospital. Choices E, F, and G are not provided in the question.
In summary, choices B and C are crucial for providing comfort and emotional support to the infant before surgery, while the other options either disrupt the routine or are not necessary for the child's well-being during hospitalization.
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.