Nokea
The nurse is reviewing general injury prevention guidelines with the pediatric department staff in the hospital. Which interventions aimed at promoting safety specifically for infants and toddlers should the nurse include in this review? Select all that apply.
- A. Ensure that crib sides are up.
- B. Place large, soft pillows in the crib.
- C. Use large, soft toys without small parts.
- D. Attach a pacifier to a stretchable piece of ribbon and pin to the infant's clothing.
- E. Allow a toddler who is toilet training privacy in the bathroom to promote autonomy.
- F. Ensure that an infant or toddler is never left unattended while lying on a changing table.
Correct Answer: A,C,F
Rationale: To promote safety for infants and toddlers, crib sides should never be left down because the child could roll and fall. Large, soft toys without small parts should be used because small parts can become dislodged and choking and aspiration may occur. For this same reason, an infant or toddler is never left unattended while lying on a changing table. Pillows, stuffed toys, comforters, or other objects should not be placed in the crib because the child can become entwined in these items and suffocate. Pacifiers should not be attached to string or ribbon because of the risk associated with choking. The child is never left alone in the bathroom, in the tub, or near any other water source because of the risk of drowning.
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A 17-year-old client is discharged to home with her newborn baby after the nurse provides information about home safety for children. Which statement by the client should alert the nurse that further teaching is required regarding home safety?
- A. I can keep my aluminum pots and pans in my lower cabinets.
- B. I will not use the microwave oven to heat my baby's formula.
- C. I have locks on all my cabinets that contain my cleaning supplies.
- D. I have a car seat that I will put in the front seat to keep my baby safe.
Correct Answer: D
Rationale: A baby car seat should never be placed in the front seat because of the potential for life-threatening injury on impact. It is perfectly safe to leave pots and pans in the lower cabinets for a child to investigate, as long as they are not made of glass, which would harm the baby if broken. Microwave ovens should never be used to heat formula because the formula heats unevenly, and it could burn and even scald the baby's mouth. Even though the bottle may feel warm, it could contain hot spots that could severely damage the baby's mouth. Any cabinets that contain dangerous items that a baby or child could swallow should be locked.
The nurse manager reviewing the purposes for applying restraints to a client determines that further education is necessary when a nursing staff member makes which statement supporting the use of a restraint?
- A. It limits movement of a limb during a painful procedure.
- B. It prevents the violent client from injuring self and others.
- C. At night it keeps the client in bed instead of wandering about.
- D. It is useful in preventing the client from pulling out intravenous lines.
Correct Answer: C
Rationale: Wrist and ankle restraints are devices used to limit the client's movement in situations when it is necessary to immobilize a limb. Restraints are not applied to keep a client in bed at night and should never be used as a form of punishment. Restraints are applied to prevent the client from injuring self or others; pulling out intravenous lines, catheters, or tubes; or removing dressings. Restraints also may be used to keep children still and from injuring themselves during treatments and diagnostic procedures. A primary health care provider's prescription is required for the use of restraints, and state and agency procedures are always followed when restraints are used.
The nurse assisting in the care of a client who is to be cardioverted should plan to set the monophasic defibrillator to which starting energy levels range, depending on the specific primary health care provider prescription?
- A. 50 to 100 joules
- B. 200 to 250 joules
- C. 250 to 300 joules
- D. 350 to 400 joules
Correct Answer: A
Rationale: Cardioversion is synchronized countershock to convert an undesirable rhythm to a stable rhythm. Cardioversion is usually started at 50 to 100 joules. When a client is cardioverted, the defibrillator is charged to the energy level prescribed by the primary health care provider, and the remaining options identify energy levels that are too high for cardioversion.
When a hospitalized child develops a rash that covers the trunk and extremities, the nurse notes in the history that the child was exposed to varicella 2 weeks ago. Which nursing intervention has priority?
- A. Immediately reassign the child's roommate.
- B. Place the child in a private room on strict isolation.
- C. Confirm the exposure occurred with the child's parent.
- D. Assess the progression of the rash and report it to the primary health care provider.
Correct Answer: B
Rationale: The child with undiagnosed rash needs to be placed on strict isolation. Varicella causes a profuse rash on the trunk with a sparse rash on the extremities. The incubation period is 14 to 21 days. It is important to prevent the spread of this communicable disease by placing the child in isolation until further diagnosis and treatment are made. None of the other options address the need to prevent the spread of the disease.
The nurse administers digoxin 0.25 \mathrm{mg by mouth rather than the prescribed dose of 0.125 \mathrm{mg to the client. After assessing the client and notifying the health care provider, which action should the nurse implement first?
- A. Write an incident report.
- B. Administer digoxin immune Fab.
- C. Tell the client about the medication error.
- D. Tell the client about the adverse effects of digoxin.
Correct Answer: A
Rationale: According to agency policy, the nurse should file an incident report when a medication error occurs to accurately document the facts. The nurse should assess the client first and then contact the primary health care provider (HCP) because in this situation the client received too much medication. The client should be informed of the error and the adverse effects in a professional manner to avoid alarm and concern. However, in many situations, the HCP prefers to discuss this with the client. Digoxin immune Fab is reserved for extreme toxicity and requires a prescription and may be prescribed depending on the client's response and the serum digoxin level.