Nokea
A nurse is preparing to administer an intramuscular (IM) injection to a 2-month-old infant. Which of the following is the preferred injection site?
- A. "Vastus lateralis"'
- B. "Deltoid muscle"'
- C. "Ventrogluteal site"'
- D. NA
Correct Answer: A
Rationale: The correct answer is A: "Vastus lateralis." For infants, the vastus lateralis muscle in the thigh is the preferred site for IM injections due to its large size, well-developed muscle mass, and minimal major blood vessels and nerves. This reduces the risk of injury and ensures proper medication absorption. The deltoid muscle (choice B) is typically used for older children and adults, not infants. The ventrogluteal site (choice C) is more commonly used for adults and older children as well. Not Applicable (choice D) does not provide any relevant information.
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Which preoperative nursing interventions should be included for a client who is scheduled to have an emergency cesarean birth?
- A. Monitoring O2 saturations and administering pain medications are postoperative interventions.
- B. Taking vital signs every 15 minutes is a postoperative intervention. Instructing the client regarding breathing exercises is not appropriate in a crisis situation when the client's anxiety is high, because information would probably not be retained. In an emergency, there is time only for essential interventions.
- C. Because this is an emergency, surgery must be performed quickly. Anxiety of the client and the family will be high. Inserting an indwelling catheter helps to keep the bladder empty and free from injury when the incision is made.
- D. The nurse should have assessed breath sounds upon admission. Breath sounds are important if the client is to receive general anesthesia, but the anesthesiologist will be listening to breath sounds in surgery in that case.
Correct Answer: C
Rationale: The correct answer is C because in an emergency cesarean birth, surgery must be performed quickly to ensure the safety of the mother and baby. Inserting an indwelling catheter is crucial to keep the bladder empty and prevent injury during the incision. This intervention helps maintain a sterile field and reduces the risk of infection. Additionally, a full bladder can impede the progress of surgery. Monitoring O2 saturations and administering pain medications (A) are postoperative interventions and not relevant in the preoperative phase. Taking vital signs every 15 minutes (B) is more appropriate for the postoperative period. Assessing breath sounds (D) is important but typically done by the anesthesiologist during surgery. Instructing the client about breathing exercises (B) may not be effective in an emergency situation where immediate interventions are necessary.
A nurse is monitoring a child whose parents are suspected of child neglect. Which of the following is an expected finding of neglect?
- A. Lack of required immunizations
- B. Parental lack of education
- C. Lower socioeconomic group
- D. Faded clothing with large shoes
Correct Answer: A
Rationale: The correct answer is A: Lack of required immunizations. Neglect refers to the failure to provide for a child's basic needs, including healthcare. Lack of immunizations puts the child at risk for preventable diseases, indicating neglect. Parental lack of education (B) or being in a lower socioeconomic group (C) do not directly indicate neglect. Faded clothing with large shoes (D) may suggest financial difficulties but does not necessarily indicate neglect.
The parents of a 4-year-old child state that they had an infant die 2 months ago during childbirth.
- A. "Our child wants to go to the cemetery to be with his sister."'
- B. "Our child asks many questions about what happened to the baby's body."'
- C. "Our child is not sleeping,eating or playing lately and we are worried."'
- D. "Our child blames himself for the baby's death because he said he didn't want a baby brother or sister."'
Correct Answer: D
Rationale: The correct answer is D because it reflects a common behavior in children who have experienced a loss - feeling guilty or blaming themselves for the death. This is known as magical thinking, where children associate their thoughts or actions with causing events. Choice A may indicate a desire for connection but doesn't directly address the child's internal struggle with guilt. Choice B shows curiosity but doesn't address the emotional impact on the child. Choice C highlights concerning behaviors but doesn't capture the underlying psychological issue of guilt. Overall, D is the best choice as it directly addresses the child's emotional response to the loss.
A nurse is assessing a client who is at 30 wks gestation during a routine prenatal visit. Which of the following findings should the nurse report to the provider?
- A. Swelling of the face
- B. Varicose veins in the calves
- C. Nonpitting 1+ ankle edema
- D. Hyperpigmentation
Correct Answer: A
Rationale: The correct answer is A: Swelling of the face. Facial swelling in a pregnant woman at 30 weeks gestation could be a sign of preeclampsia, a serious condition characterized by high blood pressure and protein in the urine. It is important to report this finding promptly to the provider for further evaluation and management to prevent complications for both the mother and the baby. Varicose veins in the calves (B) and hyperpigmentation (D) are common in pregnancy but are not urgent issues requiring immediate reporting. Nonpitting 1+ ankle edema (C) is a common finding in pregnancy but is not as concerning as facial swelling. Make sure to report any change in the severity of edema.
A nurse is monitoring a 9-year-old child on the first postoperative day following abdominal surgery.
- A. "Poker chip tool"'
- B. "FACES rating scale"'
- C. "Visual analog scale"'
- D. "Numerical 1 to 10 rating scale"'
Correct Answer: B
Rationale: The correct answer is B: "FACES rating scale." This tool uses facial expressions to assess pain in children, making it suitable for a 9-year-old who may find it challenging to express pain verbally. The other choices are not as appropriate for this age group postoperatively: A is not a recognized pain assessment tool, C and D may be too abstract for a child, and E-G are missing options.