Nokea
A nurse is preparing to administer ear drops to a 2-year-old toddler who has an ear infection and a small amount of purulent drainage visible around the ear. Which of the following techniques should the nurse use when instilling the medication?
- A. Firmly push a cotton ball into the ear canal after instilling drops.
- B. Pull the child's ear auricle upward and outward just before instilling drops.
- C. Apply clean gloves and clean the outer ear prior to instilling drops.
- D. Warm the medication container for 10 seconds in a microwave oven prior to installation.
Correct Answer: C
Rationale: Applying clean gloves and cleaning the outer ear is essential for preventing infection and ensuring that the medication is administered properly. This is a standard procedure to maintain hygiene.
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A nurse is collecting data from a 5-month-old infant who has increased intracranial pressure (ICP) resulting from hydrocephalus. Which of the following manifestations should the nurse expect?
- A. Low-pitched cry
- B. Positive Babinski reflex
- C. Insomnia
- D. Bulging fontanel
Correct Answer: D
Rationale: A bulging fontanel is a key sign of increased ICP in infants. It occurs due to pressure within the skull causing the soft spot on the head to protrude.
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 provide low-fat meals for my child.
- B. I will restrict the amount of salt in my child's meals.
- C. I will put my child in daycare to ensure that she socializes with other children.
- D. I will make sure my child washes her hands before eating.
Correct Answer: D
Rationale: Hand hygiene is crucial for preventing infections which are a significant risk for children with cystic fibrosis.
A nurse is caring for a preschooler who has epiglottitis from a streptococcal infection. Which of the following actions should the nurse take?
- A. Attempt to obtain a throat culture.
- B. Use a tongue depressor to observe the back of the throat.
- C. Apply humidified oxygen via a mask.
- D. Initiate airborne precautions.
Correct Answer: C
Rationale: This helps to keep the airways moist and can provide some relief and improve oxygenation.
A nurse in a clinic is preparing to administer pre-kindergarten vaccines to a 5-year-old child whose medical record indicates that his Immunizations are up to date. Which of the following vaccines should the nurse plan to administer?
- A. Hepatitis B (HBV)
- B. Measles
- C. mumps
- D. and rubella (MMR)
- E. Haemophilus influenzae type B (Hib)
- F. Pneumococcal conjugate vaccine (PCV)
Correct Answer: B
Rationale: The MMR vaccine is part of the pre-kindergarten immunization schedule.
A nurse in a family health clinic is collecting data as part of a routine physical examination of a client who is about to enter high school. The nurse observes an abnormal lateral curvature of the spine. The nurse should expect the provider to document which of the following disorders?
- A. Scoliosis
- B. Ankylosis
- C. Kyphosis
- D. Lordosis
Correct Answer: A
Rationale: Scoliosis is characterized by an abnormal lateral curvature of the spine.