Nokea
The nurse is developing a teaching plan for a child who is to have his cast removed. What instruction would the nurse most likely include?
- A. Applying petroleum jelly to the dry skin.
- B. Rubbing the skin vigorously to remove the dead skin.
- C. Soaking the area in warm water every day.
- D. Washing the skin with diluted peroxide and water.
Correct Answer: C
Rationale: The correct instruction for the nurse to include in the teaching plan is to advise the child to soak the area in warm water every day. Soaking the area in warm water helps to gently remove dead skin without causing irritation, facilitating the safe and comfortable removal of the cast. Applying petroleum jelly (Choice A) may not be necessary and could interfere with the cast removal process. Rubbing the skin vigorously (Choice B) can lead to skin damage and should be avoided. Washing the skin with diluted peroxide and water (Choice D) is not recommended as peroxide can be irritating to the skin and may not aid in cast removal.
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A 1-week-old infant has been in the pediatric unit for 18 hours following placement of a spica cast. The nurse observes a respiratory rate of fewer than 24 breaths/min. No other changes are noted. Because the infant is apparently well, the nurse does not report or document the slow respiratory rate. Several hours later, the infant experiences severe respiratory distress and emergency care is necessary. What should be considered if legal action is taken?
- A. Most infants have slow respirations when they are uncomfortable.
- B. The respirations of young infants are irregular, so a drop in rate is unimportant.
- C. Vital signs that are outside the expected parameters are significant and should be documented.
- D. The respiratory tract of young infants is underdeveloped, and their respiratory rate is not significant.
Correct Answer: C
Rationale: In this scenario, the correct answer is C. Any vital signs outside the expected range in an infant should be documented and reported, as they may indicate a developing condition that requires prompt attention. Choice A is incorrect because slow respirations in infants should not be dismissed without assessment and documentation. Choice B is incorrect because a drop in respiratory rate in this case was significant and should have been documented. Choice D is incorrect because even though infants have underdeveloped respiratory tracts, any abnormal respiratory rate should be taken seriously and documented for monitoring and intervention if necessary.
A nurse is inspecting the skin of a child with atopic dermatitis. What would the nurse expect to observe?
- A. Erythematous papulovesicular rash
- B. Dry, red, scaly rash with lichenification
- C. Pustular vesicles with honey-colored exudates
- D. Hypopigmented oval scaly lesions
Correct Answer: B
Rationale: In atopic dermatitis, the characteristic presentation includes a dry, red, scaly rash with lichenification. This appearance is due to chronic inflammation and scratching. Choice A is incorrect as erythematous papulovesicular rash is more indicative of conditions like contact dermatitis. Choice C is incorrect as pustular vesicles with honey-colored exudates are seen in impetigo. Choice D is incorrect as hypopigmented oval scaly lesions are more characteristic of tinea versicolor.
What should the nurse recommend to reduce the risk of sudden infant death syndrome (SIDS) in a 6-month-old infant?
- A. Place the infant on their back to sleep
- B. Use a pacifier during sleep
- C. Have the infant sleep on their side
- D. Keep the infant's room cool
Correct Answer: A
Rationale: Placing the infant on their back to sleep is the correct recommendation to reduce the risk of sudden infant death syndrome (SIDS). This sleep position has been shown to significantly decrease the incidence of SIDS. Using a pacifier during sleep (Choice B) can also help reduce the risk, but it is secondary to the back sleeping position. Having the infant sleep on their side (Choice C) is not recommended, as it increases the risk of SIDS. Keeping the infant's room cool (Choice D) may provide a comfortable sleeping environment but does not directly reduce the risk of SIDS.
A child with a diagnosis of leukemia is receiving chemotherapy. What is the most important nursing intervention?
- A. Monitor for signs of infection
- B. Monitor for signs of bleeding
- C. Monitor for signs of dehydration
- D. Monitor for signs of pain
Correct Answer: A
Rationale: The most important nursing intervention for a child with leukemia receiving chemotherapy is to monitor for signs of infection. Chemotherapy suppresses the immune system, putting the child at a higher risk of developing infections. Early detection and prompt treatment of infections are crucial to prevent complications and improve outcomes. Monitoring for signs of bleeding (choice B), dehydration (choice C), and pain (choice D) are also important aspects of care, but in this scenario, the priority is to prevent and manage infections due to the compromised immune system.
A 1-week-old infant has been in the pediatric unit for 18 hours following placement of a spica cast. The nurse observes a respiratory rate of fewer than 24 breaths/min. No other changes are noted. Because the infant is apparently well, the nurse does not report or document the slow respiratory rate. Several hours later, the infant experiences severe respiratory distress, and emergency care is necessary. What should be considered if legal action is taken?
- A. Most infants have slow respirations when they are uncomfortable.
- B. The respiratory rates of young infants are irregular, so a drop in rate is unimportant.
- C. Vital signs that are outside the expected parameters are significant and should be documented.
- D. The respiratory tract of young infants is underdeveloped, and their respiratory rate is not significant.
Correct Answer: C
Rationale: In this scenario, the nurse failed to report or document the slow respiratory rate of the infant, which later led to severe respiratory distress. It is crucial to understand that any vital signs outside the expected range in an infant should be documented and reported promptly. This documentation is vital for monitoring the infant's condition, identifying potential issues, and ensuring timely intervention if needed. Choices A, B, and D are incorrect because they downplay the significance of abnormal vital signs and fail to emphasize the importance of documentation and reporting in infant care.