Nokea
A nurse is working in a pediatric clinic and a mother brings in her 13 month old child who has Down Syndrome. The mother reports, 'My child's muscles feel weak and he isn't moving well. My RN friend checked his reflexes and she said they are diminished.' Which of the following actions should the nurse take first?
- A. Contact the physician immediately
- B. Have the patient go to X-ray for a c-spine work-up.
- C. Start an IV on the patient
- D. Position the child's neck in a neutral position
Correct Answer: D
Rationale: An atlanto-axial dislocation may have occurred, common in Down Syndrome. Positioning the child's neck in a neutral c-spine posture is the first step to prevent further injury, followed by contacting the doctor.
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The nurse needs nasotracheal suctioning. The nurse explains the procedure to the client and performs hand hygiene. Prioritize the nurse's remaining actions to perform the nasotracheal suctioning by placing each step in the correct order.
- A. Prepare suction supplies and equipment and pour sterile saline into a sterile container.
- B. Place finger over suction control port of catheter and suction intermittently while withdrawing the catheter.
- C. Put on sterile gloves.
- D. Lubricate the catheter with sterile saline, insert into naris, and advance into pharynx.
- E. When the client inhales, advance the catheter into the trachea.
- F. Pick up suction catheter with the dominant hand and attach it to connection tubing; avoid contamination of the glove on the dominant hand.
- G. Place tip into sterile saline container while applying suction to clear secretions from the tubing
Correct Answer: A,C,F,D,E,B,G
Rationale: A: Preparing supplies comes first. C: Sterile gloves maintain asepsis. F: Handling catheter keeps dominant hand sterile. D: Lubrication aids insertion. E: Advancing during inhalation ensures tracheal placement. B: Intermittent suction prevents trauma. G: Clearing tubing prevents reinsertion of secretions.
A spinal change occurring with pregnancy that alters mobility is:
- A. scoliosis.
- B. kyphosis.
- C. lordosis.
- D. ankylosing spondylitis.
Correct Answer: C
Rationale: The spinal change occurring with pregnancy is lordosis. This occurs due to the weight of the enlarging uterus and the affect of gravity.
Distraction therapy is:
- A. Focusing one's attention on stimuli other than pain
- B. Cognitive reappraisal
- C. The replacement of positive images of pain with other images
- D. The use of medication and meditation
Correct Answer: A
Rationale: The focus of distraction therapy is on positive stimuli rather than negative input, helping to manage pain perception.
The NSAID that is comparable to morphine in efficacy is:
- A. Feldene.
- B. Stodal.
- C. Toradol.
- D. Elavil.
Correct Answer: C
Rationale: Toradol is the first injectable NSAID equal to morphine in efficacy.
The LPN is assisting the client with an NG tube with activities of daily living. Which of these statements would indicate need for teaching reinforcement?
- A. Since I'm not eating or drinking by mouth, I do not need to brush my teeth as often.
- B. I should remain sitting up at a 45-degree angle or higher for 30 minutes after a feeding.
- C. I can clean around the tube with water and mild soap.
- D. I should avoid using Vaseline around the nostril and tube.
Correct Answer: A
Rationale: Even when an NG tube is in place, the client still should brush his or her teeth twice daily. Good oral hygiene reduces the risk of introducing bacteria that may cause an infection.