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Nurse cautioning mother of 8 mo infant about safety. Which statement by mother indicates understanding of safety for infant?
- A. My baby loved to play with crib gym, but I took it from him
- B. I just bought a soft mattress so my baby will sleep better
- C. My baby really likes sleeping on fluffy pillow we just got for him
- D. I just bought a child-safety gate that folds like accordion
Correct Answer: A
Rationale: Correct Answer: A
Rationale: Removing the crib gym is crucial as it can pose a choking hazard. Infants should sleep on a firm mattress to reduce the risk of suffocation, making option B incorrect. Option C is unsafe as soft pillows increase the risk of suffocation. Option D, while mentioning a safety gate, doesn't directly address infant safety.
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Occupational health nurse is caring for employee with chemical burn from unknown chemical. Which intervention should nurse include in care plan?
- A. Irrigate affected area with running water
- B. Wash affected area with antibacterial soap
- C. Brush chemical off skin & clothing
- D. Apply neutralizing agent
Correct Answer: C
Rationale: The correct answer is C: Brush chemical off skin & clothing. This intervention is crucial to prevent further exposure and damage from the unknown chemical. By brushing off the chemical, the nurse can minimize the contact time and reduce the risk of more severe burns. Irrigating with water (choice A) may spread the chemical or react with it, worsening the burn. Washing with antibacterial soap (choice B) can also react with the chemical and cause more harm. Applying a neutralizing agent (choice D) can potentially worsen the burn if the wrong agent is used. Therefore, choice C is the best initial intervention to prevent further harm.
Nurse caring for 5 yo whose parents report she fears painful procedures, like shots. Which strategies should nurse use to try to help ease child's fear? (Select all that apply.)
- A. Invite child to assist with mealtime activities
- B. Cluster invasive procedures whenever possible
- C. Assign caregivers with whom the child is familiar
- D. Have parents bring in favorite toy from home
- E. Engage child in pretend play with toy medical kit
Correct Answer: A,D,E
Rationale: Correct Answer: A, D, E
Rationale:
A: Inviting the child to assist with mealtime activities can help build trust and rapport, making the child more comfortable and less fearful in the healthcare setting.
D: Having parents bring in the child's favorite toy from home can provide comfort and distraction, helping to alleviate fear and anxiety during procedures.
E: Engaging the child in pretend play with a toy medical kit allows for familiarization with medical tools in a non-threatening way, helping to reduce fear and anxiety related to medical procedures.
Summary:
B: Clustering invasive procedures may minimize the number of times the child needs to undergo such procedures but does not directly address the fear.
C: Assigning caregivers familiar to the child is important for comfort but may not directly address the fear of painful procedures.
A nurse on med-surg unit has received change-of-shift report & will care for 4 clients. Which of following client's needs may nurse assign to AP?
- A. Feeding client who was admitted 24h ago with aspiration pneumonia
- B. Reinforcing teaching w/ client who is learning to walk using quad cane
- C. Reapplying a condom catheter for client who has urinary incontinence
- D. Applying sterile dressing to pressure ulcer
Correct Answer: C
Rationale: The correct answer is C. The nurse can assign the task of reapplying a condom catheter for a client with urinary incontinence to an unlicensed assistive personnel (AP) because it is a routine, non-invasive procedure that does not require specialized nursing skills. The AP can be trained to perform this task safely under the nurse's supervision.
A: Feeding a client with aspiration pneumonia requires assessment and monitoring for signs of aspiration, which should be done by a licensed nurse.
B: Teaching a client to walk using a quad cane involves assessing the client's safety and gait, which should be done by a licensed nurse.
D: Applying a sterile dressing to a pressure ulcer requires knowledge of wound care principles and infection control, which should be done by a licensed nurse.
Nurse talking to parents of school-age child who describe many issues that concern them. Which problem should nurse identify as priority for more assessment & intervention?
- A. He doesn't keep up with other kids in activities like running & jumping
- B. He keeps trying to find ways around household rules; he always wants to make deals with us
- C. We think he is trying too hard to excel in math just to get top grades in his class
- D. He is always afraid the kids at school will laugh at him b/c he likes to sing & write poems
Correct Answer: A
Rationale: The correct answer is A because the child's inability to keep up with other kids in physical activities like running and jumping could indicate underlying physical or developmental issues that require further assessment and intervention. This could be a sign of motor skill delays, muscle weakness, or coordination problems that may impact the child's overall physical health and well-being. Options B, C, and D focus on behavioral, academic, and social issues which are important but not as urgent as addressing potential physical limitations that could affect the child's daily functioning and quality of life.
Nurse reviewing CDC's immunization recommendations with parents of adolescent. Which should nurse include in this discussion?
- A. "rotavirus"
- B. varicella
- C. herpes zoster
- D. HPV
- E. seasonal influenza
Correct Answer: B, D, E
Rationale: The correct answers are B (varicella), D (HPV), and E (seasonal influenza) because these are recommended immunizations for adolescents by the CDC. Varicella vaccine protects against chickenpox, HPV vaccine prevents certain types of cancers, and seasonal influenza vaccine helps prevent the flu. Rotavirus (A) is typically given to infants, not adolescents. Herpes zoster (C) is recommended for older adults, not adolescents.