Nokea
The nurse is continuing to care for the child. Select the 3 priority actions that the nurse should take.
- A. Review cast care instructions with the child's parents
- B. Administer ibuprofen 200 mg PO
- C. Place a nonadherent dressing on the right knee abrasion.
- D. Explain the cast application procedure to the child.
- E. Apply ice packs to the fingers and along the right forearm.
- F. Elevate the affected forearm with pillows.
Correct Answer: A,B,F
Rationale: The correct answers are A, B, and F. A) Reviewing cast care instructions with the child's parents ensures proper care at home. B) Administering ibuprofen helps manage pain and inflammation. F) Elevating the affected forearm reduces swelling. Choices C, D, and E are incorrect because C) placing a nonadherent dressing is not a priority over cast care, D) explaining cast application to the child is not essential for ongoing care, and E) applying ice packs to fingers and forearm is not as crucial as administering pain relief and elevating the affected area.
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A nurse is planning care for a toddler who has epiglottitis. Which of the following interventions should the nurse include?
- A. Offer a high-calorie, high-protein diet.
- B. Administer pancreatic enzymes with meals.
- C. Initiate droplet precautions.
- D. Carefully suction the child's oropharynx to remove secretions.
Correct Answer: C
Rationale: The correct answer is C: Initiate droplet precautions. Epiglottitis is a serious condition that involves inflammation of the epiglottis, which can lead to airway obstruction. Droplet precautions are necessary to prevent the spread of infection, as epiglottitis is usually caused by a bacterial infection. Offering a high-calorie, high-protein diet (choice A) is not the priority in the acute phase of epiglottitis. Administering pancreatic enzymes with meals (choice B) is unrelated to the care of a toddler with epiglottitis. Carefully suctioning the child's oropharynx to remove secretions (choice D) can potentially worsen the condition by triggering a gag reflex and causing further airway obstruction.
A nurse is caring for an infant who has diaper dermatitis. Which of the following actions should the nurse take?
- A. Apply talcum powder to the irritated area.
- B. Wipe stool from the skin using store-bought baby wipes.
- C. Apply zinc oxide ointment to the irritated area.
- D. Wipe urine from the skin using a cool cloth.
Correct Answer: C
Rationale: The correct answer is C: Apply zinc oxide ointment to the irritated area. Zinc oxide ointment provides a protective barrier on the skin, helping to soothe and heal diaper dermatitis. It also helps to keep moisture away from the irritated skin, promoting healing.
Incorrect options:
A: Applying talcum powder can further irritate the skin as it can be abrasive.
B: Store-bought baby wipes may contain chemicals or fragrances that can worsen the condition.
D: Wiping urine with a cool cloth is a good practice, but it does not address the issue of diaper dermatitis.
Overall, option C is the best choice as it directly addresses the diaper dermatitis by providing a protective barrier and promoting healing.
A nurse is preparing to admit a 6-year-old with varicella to the pediatric unit. Which of the following actions should the nurse take?
- A. Assign the child to a negative air pressure room
- B. Administer aspirin to the child for fever
- C. Use droplet precautions when caring for the child
- D. Assess the child for health spots
Correct Answer: A
Rationale: The correct answer is A: Assign the child to a negative air pressure room. Varicella (chickenpox) is highly contagious and spreads through airborne particles. Placing the child in a negative air pressure room helps prevent the spread of the virus to other patients and staff. Administering aspirin to a child with varicella can lead to Reye's syndrome, making choice B incorrect. Droplet precautions are used for illnesses like influenza or pertussis, not varicella, so choice C is incorrect. Choice D is incorrect because the characteristic rash in varicella is not described as health spots.
The nurse is continuing to care for the child. After reviewing the discharge instructions with the family, which of the following statements by a parent indicate an understanding of the discharge teaching?
- A. We should notify the provider if the cast becomes loose over time.
- B. It is important that our child avoids placing anything inside the cast.
- C. We should prop the casted arm on pillows for the next 24 hours.
- D. We should expect the swelling to get better.
- E. We need to be very careful about how we handle the cast for the first 2 days while it dries.
Correct Answer: A,B,C,D,E
Rationale: [1,1,1,1,1]
Parent Statement: We should notify the provider if the cast becomes loose over time.
Reflects Understanding: This statement shows awareness of the need for prompt action in case of an issue with the cast, ensuring proper care.
Needs Reinforcement: None. This statement is crucial for the child's well-being.
Parent Statement: It is important that our child avoids placing anything inside the cast.
Reflects Understanding: This statement highlights the importance of maintaining the integrity of the cast to prevent complications.
Needs Reinforcement: None. Preventing foreign objects from entering the cast is essential.
Parent Statement: We should prop the casted arm on pillows for the next 24 hours.
Reflects Understanding: Proper elevation helps reduce swelling and promotes healing.
Needs Reinforcement: None. Elevation is a standard practice in cast care.
Parent Statement: We should expect the swelling to get better.
Reflects Understanding: Knowing that swelling should improve indicates awareness of the expected healing process
A nurse is providing teaching about home safety to the adult child of an older adult client who is postoperative following knee replacement surgery. Which of the following instructions should the nurse include?
- A. Encourage the client to avoid wearing shoes at home.
- B. Place a throw rug over electrical cords.
- C. Mark the edges of the doorway to the house with tape.
- D. Ensure that area rugs have rubber backs.
Correct Answer: D
Rationale: The correct answer is D: Ensure that area rugs have rubber backs. This instruction is important because rugs with rubber backs are less likely to slip, reducing the risk of falls for the older adult post knee replacement surgery. Choice A is incorrect as wearing shoes at home can increase the risk of falls due to slippery surfaces. Choice B is incorrect as placing a throw rug over electrical cords can create a tripping hazard. Choice C is incorrect as marking the edges of the doorway with tape does not address the risk of tripping over rugs.