Nokea
The nurse is assisting another member of the health care team who is placing a peripherally inserted catheter in a 10-year-old with peritonitis from a ruptured appendix. The family is present in the treatment room to support the child. The nurse observes the other team member has contaminated a sterile glove. The nurse should:
- A. Discuss the incident with the team member after the event.
- B. Report the incident to the nursing unit manager.
- C. Tell the team member the glove is contaminated.
- D. Ask the family to leave before confronting the team member.
Correct Answer: C
Rationale: Immediately addressing the contamination maintains sterility and patient safety.
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Assessment of a school-age child with Guillain-Barré syndrome reveals absent gag and cough reflexes. Which of the following nursing diagnoses should receive the highest priority during the acute phase?
- A. Risk for infection due to altered immune system.
- B. Ineffective breathing pattern related to neuromuscular impairment.
- C. Impaired swallowing related to neuromuscular impairment.
- D. Total urinary incontinence related to fluid losses.
Correct Answer: B
Rationale: Absent gag and cough reflexes increase the risk of respiratory compromise, making ineffective breathing pattern the highest priority.
The parent of an 18-year-old with chronic renal disease states, "My son has so many problems. I'm really worried that he will not get the right care if he gets sick at college." The nurse should tell the parent:
- A. I can have his records sent to the school's health center.
- B. Make sure your son always carries his nephrologist's phone number.
- C. Your son can make an e-health history to facilitate his care if he gets sick away from home.
- D. Your son is going to need to learn to manage his own disease.
Correct Answer: D
Rationale: Promoting self-management is key.
A preschooler with a fractured femur of the left leg in traction tells the nurse that his leg hurts. It is too early for pain medication. The nurse should:
- A. Place a pillow under the child's buttocks to provide support.
- B. Remove the weight from the left leg.
- C. Assess the feet for signs of neurovascular impairment.
- D. Reposition the pulleys so the traction is looser.
Correct Answer: C
Rationale: Assessing for neurovascular impairment is critical, as pain could indicate compromised circulation or nerve function.
A 15-year-old has been diagnosed with acute glomerulonephritis and has been in the hospital for 1 day. Which of the following findings requires immediate action?
- A. Large amount of generalized edema.
- B. Urine specific gravity of 1.030.
- C. Large amount of albumin in the urine.
- D. 24-hour output of 1,500 mL.
Correct Answer: A
Rationale: Severe edema could indicate worsening condition.
A 9-month-old infant with eczema has lesions that are secondarily infected. Which of the following is most appropriate to help the parents best meet the needs of the child?
- A. Preventing siblings from being in close contact.
- B. Sending the child to day care as usual.
- C. Playing video games for several hours each evening.
- D. Playing with the child every day.
Correct Answer: D
Rationale: Playing with the child daily promotes emotional bonding and normal development, which is critical for a 9-month-old. Preventing sibling contact is unnecessary unless siblings are ill, day care may risk further infection, and video games are inappropriate for an infant.