Nokea
The nurse is preparing to suction a tracheotomy on an infant. The nurse prepares the equipment for the procedure and should turn the suction to which setting?
- A. 60 mm Hg
- B. 90 mm Hg
- C. 110 mm Hg
- D. 120 mm Hg
Correct Answer: B
Rationale: The suctioning procedure for pediatric clients varies from that used for adults. Suctioning in infants and children requires the use of a smaller suction catheter and lower suction settings as compared with those used for adults. Suction settings for a neonate are usually 60 to 80 mm Hg; for an infant, 80 to 100 mm Hg; and, for larger children, 100 to 120 mm Hg. The primary health care provider prescription and agency procedures are always followed.
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The nurse responds to a call bell and finds a client lying on the floor after a fall. The nurse suspects that the client's arm may be broken. Which immediate action should the nurse take?
- A. Immobilize the arm.
- B. Take a set of vital signs.
- C. Call the radiology department.
- D. Ask the client to describe what happened.
Correct Answer: A
Rationale: When a fracture is suspected, it is imperative that the area be splinted before the client is moved. Emergency help should be called for if the client is external to a hospital, and a primary health care provider is called if the client is hospitalized. Vital signs would be taken, but this is not the immediate action. The primary health care provider rather than the nurse prescribes an x-ray examination. The nurse should remain with the client and provide realistic reassurance. Although the details of the fall are important, such a discussion is not an immediate need.
During the assessment, the nurse notes that the child's genitals are swollen. The nurse suspects that the child is being sexually abused. Which action by the nurse is of primary importance?
- A. Document the child's physical findings.
- B. Report the case because abuse is suspected.
- C. Refer the family to appropriate support groups.
- D. Assist the family with identifying resources and support systems.
Correct Answer: B
Rationale: The primary legal responsibility of the nurse when child abuse is suspected is to report the case. All 50 states require health care professionals to report all cases of suspected abuse. Although documenting the assessment findings, assisting the family, and referring the family to appropriate resources and support groups is important, the primary legal responsibility is to report the case. Although the remaining options are appropriate, reporting the findings has priority.
The nurse prepares to admit a newborn born with spina bifida, myelomeningocele. Which nursing action is most important for the care for this infant?
- A. Monitoring the temperature
- B. Monitoring the blood pressure
- C. Inspecting the anterior fontanel for bulging
- D. Monitoring the specific gravity of the urine
Correct Answer: C
Rationale: Intracranial pressure is a complication that is associated with spina bifida. A sign of intracranial pressure in the newborn infant with spina bifida is a bulging anterior fontanel. The newborn infant is at risk for infection before the surgical procedure and the closure of the gibbus, and monitoring the temperature is an important intervention; however, assessing the anterior fontanel for bulging is most important. A normal saline dressing is placed over the affected site to maintain the moisture of the sac and its contents. This prevents tearing or breakdown of skin integrity at the site. Blood pressure is difficult to assess during the newborn period, and it is not the best indicator of infection or a potential complication. Urine concentration is not well developed during the newborn stage of development.
The nurse is checking the fundus of a postpartum woman and notes that the uterus is soft and spongy. Which nursing action is appropriate initially?
- A. Encourage the mother to ambulate.
- B. Notify the primary health care provider.
- C. Massage the fundus gently until it is firm.
- D. Document fundal position, consistency, and height.
Correct Answer: C
Rationale: If the fundus is boggy (soft), it should be massaged gently until it is firm and the client is observed for increased bleeding or clots. Option 1 is an inappropriate action at this time. The nurse should document the fundal position, consistency, and height; the need to perform fundal massage; and the client's response to the intervention. The primary health care provider will need to be notified if uterine massage is not helpful.
The nurse prepares for a client in leg traction to be admitted to the nursing unit. The nurse asks the unlicensed assistive personnel to obtain which essential item that will be needed to assist the client to move in bed while in leg traction?
- A. A foot board
- B. Extra pillows
- C. A bed trapeze
- D. An electric bed
Correct Answer: C
Rationale: A trapeze is essential to allow the client to lift straight up while being moved so that the amount of pull exerted on the limb in traction is not altered. A foot board and extra pillows do not facilitate moving. Either an electric bed or a manual bed can be used for traction, but this does not specifically assist the client with moving in bed.