Nokea
How would the nurse position the auricle when administering the ear drops?
- A. Up and back
- B. Down and back
- C. Up and out
- D. Down and out
Correct Answer: A
Rationale: For children 3 years and older, pulling the auricle up and back straightens the ear canal for effective ear drop administration.
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.
Which actions will the nurse implement?
- A. Assess rectal temperature every 4 hours.
- B. Administer acetaminophen as ordered.
- C. Assess skin turgor.
- D. Restrict fluids.
- E. Assess level of consciousness.
Correct Answer: B,C,E
Rationale: Administering acetaminophen, assessing skin turgor, and monitoring consciousness address fever and dehydration risks; rectal temperatures are avoided in pediatrics.
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.
Which restraint is most appropriate for the insertion of an intravenous line in a scalp vein of an infant?
- A. Mummy
- B. Clove hitch
- C. Jacket
- D. Elbow
Correct Answer: A
Rationale: A mummy restraint immobilizes the infant safely for scalp vein IV insertion.
Where is the best site for giving an IM injection to a 15-month-old child?
- A. Ventrogluteal muscle
- B. Dorsogluteal muscle
- C. Deltoid muscle
- D. Vastus lateralis muscle
Correct Answer: D
Rationale: The vastus lateralis is safe for IM injections in children due to its lack of major blood vessels and nerves.