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A nurse is planning care for a school-age child who is 4 hr postoperative following appendicitis. Which of the following actions should the nurse include in the plan of care?
- A. Apply a warm compress to the operative site once daily.
- B. Administer analgesics on a scheduled basis for the first 24 hr.
- C. Give cromolyn nebulized solution every 8 hr.
- D. Offer small amounts of clear liquids 6 hr following surgery.
Correct Answer: B
Rationale: The correct answer is B: Administer analgesics on a scheduled basis for the first 24 hr. This is essential postoperatively to manage pain effectively and improve the child's comfort level. Pain management is crucial in the early stages following surgery to prevent complications and aid in the child's recovery. Applying a warm compress (choice A) may not be appropriate for the surgical site and could potentially cause harm. Giving cromolyn nebulized solution (choice C) is not indicated for pain management postoperatively. Offering clear liquids (choice D) too soon after surgery could increase the risk of complications such as nausea, vomiting, or aspiration.
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Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.
- A. Provide the client, with foods that have a variety of textures, Accept the client’s belief about "forbidden" foods, Focus on the client’s underlying feelings of lack of control, Encourage the client to limit fasting, Provide a structured meal environment.
- B. Bulimia Nervosa, Binge eating disorder, Anorexia nervosa, Avoidant/restrictive food intake disorder.
- C. Cardiac function with ECG, Weight on a daily basis, Calcium level, Vital signs every 8 hr, Behavior 15min after meals.
Correct Answer: A[2,4],B[2],C[0,4]
Rationale: Action to Take: Provide the client with foods that have a variety of textures, Encourage the client to limit fasting; Potential Condition: Anorexia nervosa; Parameter to Monitor: Weight on a daily basis, Behavior 15 minutes after meals.
Rationale: In anorexia nervosa, the client typically has a fear of gaining weight, leading to restrictive eating habits. Providing foods with different textures can help normalize eating habits and improve nutrition. Encouraging the client to limit fasting can help address the underlying issue of restricted food intake. Weight monitoring is crucial in assessing nutritional status, while monitoring behavior post-meals can provide insights into the client's relationship with food. Bulimia nervosa and binge eating disorder are not the most likely conditions based on the client's symptoms. Monitoring cardiac function with ECG and calcium level are not the primary parameters for assessing progress in anorexia nervosa.
A nurse is caring for a child who has cystic fibrosis and requires postural drainage. Which of the following actions should the nurse take?
- A. Perform the procedure prior to meals.
- B. Hold hand flat to perform percussions on the child.
- C. Administer a bronchodilator after the procedure.
- D. Perform the procedure twice each day.
Correct Answer: A
Rationale: The correct answer is A: Perform the procedure prior to meals. Postural drainage helps clear mucus from the lungs. Performing it before meals prevents aspiration since the child's stomach will be empty. This timing also maximizes the effectiveness of postural drainage by clearing the airways before meals, which can help improve breathing.
B: Holding hand flat for percussions is incorrect as cupped hands are used to provide effective percussions.
C: Administering a bronchodilator after the procedure does not relate to the timing of postural drainage.
D: Performing the procedure twice each day is not specific to the timing of postural drainage.
A nurse on a pediatric unit is caring for four children. The nurse should use droplet precautions for which of the following children?
- A. A school-age child who has viral conjunctivitis
- B. A preschool-age child who has pediculosis capitis
- C. A toddler who has seasonal influenza
- D. An adolescent who has hepatitis A
Correct Answer: C
Rationale: The correct answer is C: A toddler who has seasonal influenza. Droplet precautions are required for diseases transmitted via respiratory droplets, such as influenza. Seasonal influenza is highly contagious through respiratory secretions, making it crucial to prevent transmission. The other choices do not require droplet precautions: A - viral conjunctivitis is spread through direct contact with eye secretions, B - pediculosis capitis (head lice) is spread through direct head-to-head contact, and D - hepatitis A is primarily spread through the fecal-oral route. Therefore, C is the correct choice for droplet precautions.
A nurse is teaching a group of school-age children about healthy snack options. Which of the following snacks should the nurse include?
- A. Cheesecake
- B. Air-popped popcorn
- C. Milkshake made with whole milk
- D. Baked potato chips
Correct Answer: B
Rationale: The correct answer is B: Air-popped popcorn. It is a healthy snack option for school-age children because it is low in calories and high in fiber, making it a satisfying and nutritious choice. Popcorn is a whole grain snack that provides essential nutrients like fiber and antioxidants. It is a good alternative to sugary or high-fat snacks. Cheesecake (A) is high in sugar and saturated fat, not a healthy choice. Milkshake made with whole milk (C) is high in calories, sugar, and saturated fat. Baked potato chips (D) may be lower in fat than regular chips but are still high in calories and lack the fiber content of popcorn.
A nurse in the emergency department is caring for a 10-year-old child. The nurse is assessing the child. Which of the following findings require follow-up? Select the 5 findings that require follow-up.
- A. Temperature
- B. Heart rate
- C. Report of pain
- D. Respiratory rate
- E. Tonsillar findings
- F. Oxygen saturation
Correct Answer: A,B,C,D,E,F
Rationale: The correct answer includes all options (A, B, C, D, E, F) because they are essential vital signs and key indicators of the child's health status. Temperature (A), heart rate (B), respiratory rate (D), and oxygen saturation (F) are crucial physiological parameters that can indicate underlying health issues if abnormal. Report of pain (C) is important to assess the child's comfort and potential underlying conditions. Tonsillar findings (E) could indicate infections or other throat issues. Follow-up on all these findings is necessary for a comprehensive assessment of the child's health.