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The nurse gives an injection in a patients room. How should the nurse dispose of the needle?
- A. Remove the needle from the syringe and dispose of it in a proper container.
- B. Dispose of the syringe and needle in a rigid, puncture-resistant container in the patients room.
- C. Close the safety cover on the needle and return it to the medication preparation area for proper disposal.
- D. Place the syringe and needle in a rigid, puncture-resistant container in an area outside of the patients room.
Correct Answer: B
Rationale: Disposing of the syringe and needle in a rigid, puncture-resistant container in the patient?s room ensures safe, immediate disposal near the point of use. Removing the needle, transporting it, or disposing outside the room increases risk of injury or contamination.
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A toddler is being sent to the operating room for surgery at 9 AM. As the nurse prepares the child, what is the priority intervention?
- A. Administering preoperative antibiotic
- B. Verifying that the child and procedure are correct
- C. Ensuring that the toddler has been NPO since midnight
- D. Informing the parents where they can wait during the procedure
Correct Answer: B
Rationale: Verifying the correct child and procedure is the priority to ensure safety and prevent errors. Administering antibiotics is secondary, clear liquids can be given up to 2 hours before surgery, and informing parents about waiting areas is important but not the priority.
A 7-year-old is identified as being at risk for skin breakdown. What intervention should the nursing care plan include?
- A. Massaging reddened bony prominences
- B. Teaching the parents to turn the child every 4 hours
- C. Ensuring that nutritional intake meets requirements
- D. Minimizing use of extra linens, which can irritate the childs skin
Correct Answer: C
Rationale: Adequate nutrition prevents skin breakdown by supporting tissue health, especially in NPO children. Massaging bony prominences risks tissue damage, turning should occur every 2 hours by the nurse, and linens don?t typically cause irritation if managed properly.
A nurse must do a venipuncture on a 6-year-old child. What consideration is important in providing atraumatic care?
- A. Use an 18-gauge needle if possible.
- B. Show the child the equipment to be used before the procedure.
- C. If not successful after four attempts, have another nurse try.
- D. Restrain the child completely.
Correct Answer: B
Rationale: Showing the child the equipment before the procedure reduces fear and supports atraumatic care. An 18-gauge needle is too large, a two-try policy (four attempts total) is preferred, and full restraint is unnecessary, favoring therapeutic hugging instead.
A critically ill child has hyperthermia. The parents ask the nurse to give an antipyretic such as acetaminophen. How should the nurse respond to the parents?
- A. Febrile seizures can result.
- B. Antipyretics may cause malignant hyperthermia.
- C. Antipyretics are of no value in treating hyperthermia.
- D. Liver damage may occur in critically ill children.
Correct Answer: C
Rationale: Antipyretics are ineffective for hyperthermia, as the body?s temperature set point is normal, requiring cooling measures instead. Seizures are linked to fever, not hyperthermia; malignant hyperthermia is unrelated to antipyretics; and while liver damage is a risk with acetaminophen, it?s not the primary reason.
A 10-year-old child requires daily medications for a chronic illness. Her mother tells the nurse that the child continually forgets to take the medicine unless reminded. What nursing action is most appropriate to promote adherence to the medication regimen?
- A. Establish a contract with her, including rewards.
- B. Suggest time-outs when she forgets her medicine.
- C. Discuss with her mother the damaging effects of her rescuing the child.
- D. Ask the child to bring her medicine containers to each appointment so they can be counted.
Correct Answer: A
Rationale: Establishing a behavioral contract with rewards encourages adherence by addressing barriers like side effects or scheduling and motivates the child. Time-outs are punitive, discussing maternal rescuing is less effective, and checking containers monitors but doesn?t promote self-responsibility.