Nokea
After instilling nose drops, the nurse will keep the infant in the head down position for at least __ seconds.
Correct Answer: 30
Rationale: Retaining the head-down position for 30 seconds allows nose drops to penetrate deeply into the nostril.
You may also like to solve these questions
What is the nurse's most effective response?
- A. No. It is over before you know it.'
- B. Yes. It will sting a little.'
- C. No. Would you like to see the syringe?'
- D. Yes. Your mom and I are going to hold you to help you be still.'
Correct Answer: B
Rationale: A truthful response about a slight sting builds trust and prepares the child for the IM injection.
How would the nurse record the infant's urine output?
- A. 47 mL
- B. 44.5 mL
- C. 43.5 mL
- D. 40.5 mL
Correct Answer: B
Rationale: Subtracting the dry diaper weight (2.5 g) from the wet diaper weight (47 g) yields 44.5 mL of urine output.
Which intervention will the nurse implement when suctioning a tracheostomy?
- A. Suction for two to three breaths.
- B. Clear the catheter with water after suctioning for reuse.
- C. Apply suction for no more than 15 seconds.
- D. Establish a regular schedule for suctioning.
Correct Answer: C
Rationale: Limiting suction to 15 seconds prevents hypoxia and tissue damage during tracheostomy suctioning.
What position will the nurse explain the child will assume for this procedure?
- A. On your stomach with your head turned to the side.'
- B. On your side, keeping the legs bent and the head arched back.'
- C. On your back with your legs extended straight out.'
- D. On your side with the knees bent and the head close to the knees.'
Correct Answer: D
Rationale: The side-lying position with knees bent and head close to knees facilitates safe lumbar puncture.
Which patient assessment requires immediate intervention?
- A. Toddler with an axillary temperature of 99?°F
- B. School-age child with widening pulse pressure
- C. Infant pulse rate of 100 beats/minute
- D. Adolescent with a respiratory rate of 28 breaths/minute
Correct Answer: B
Rationale: Widening pulse pressure may indicate increased intracranial pressure, requiring immediate intervention.