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A 9-year-old child for an IV catheter insertion
A nurse is preparing a 9-year-old child for an IV catheter insertion. Which of the following actions should the nurse take first?
- A. Allow the child to see and touch IV tubing and supplies.
- B. Explain to the child's parents what role they will have during the procedure.
- C. Describe the procedure using visual aids.
- D. Ask the child what he knows about the procedure.
Correct Answer: D
Rationale: The correct answer is D, asking the child what he knows about the procedure first. This step is crucial as it helps assess the child's understanding, address any misinformation, and tailor the explanation to the child's knowledge level. It also promotes trust and cooperation. Option A may increase anxiety as seeing the supplies without understanding can be intimidating. Option B involves parents before addressing the child directly. Option C may overwhelm the child with too much information at once.
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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 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.
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.
A client who is postoperative immediately following a tonsillectomy
A nurse is caring for a client who is postoperative immediately following a tonsillectomy. Which of the flowing snacks should the nurse offer the client?
- A. Cranberry juice
- B. Ice-cream
- C. Hot tea
- D. Italian ice
Correct Answer: B,D
Rationale: The correct snacks to offer a client post-tonsillectomy are ice-cream and Italian ice. Ice-cream is soft, cold, and soothing, helping to reduce pain and inflammation. Italian ice is also cold and can provide relief. Cranberry juice and hot tea are acidic and may irritate the surgical site. Ice-cream and Italian ice are the best choices as they are gentle on the throat and provide comfort without causing discomfort.