Nokea
The nurse observes an 18 month old who has been admitted with a respiratory tract infection (see figure). The nurse should fi rst:
- A. Position the child supine
- B. Call the rapid response team
- C. Offer the child a carbonated drink
- D. Place the child in a croup tent
Correct Answer: D
Rationale: The child is in respiratory distress and is sitting in a position to relieve the airway obstruction; the nurse should provide a humidifi ed environment with a croup tent with cool mist to facilitate breathing and liquefy secretions. The child should remain sitting to facilitate breathing; the nurse should allow the child to determine the most comfortable position. After the child is breathing normally, the nurse can offer fl uids; the physician also may order intravenous fluids. The nurse can call the rapid response team if the respiratory distress is not relieved by using a croup tent or other vital signs changes indicate further distress.
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During a home visit, the public health nurse assesses the peritoneal catheter exit site of a child with chronic renal failure. Which of the following findings should lead the nurse to formulate the nursing diagnosis Risk for infection?
- A. Dialysate leakage.
- B. Granulation tissue.
- C. Increased time for drainage.
- D. Tissue swelling.
Correct Answer: A
Rationale: Leakage increases infection risk.
The nurse is discharging a baby with clubfoot who has had a cast applied. The nurse should provide additional teaching to the parents if they state:
- A. I should call if I see changes in the color of the toes under the cast.'
- B. I should use a pillow to elevate my child's foot as he sleeps.'
- C. My baby will need a series of casts to fix her foot.'
- D. Having a cast should not prevent me from holding my baby.'
Correct Answer: B
Rationale: Using a pillow to elevate the foot may alter the cast's corrective positioning, requiring additional teaching to avoid this practice.
A 2-year-old tells his mother he is afraid to go to sleep because 'the monsters will get him.' The nurse should tell his mother to:
- A. Allow him to sleep with his parents in their bed whenever he is afraid.
- B. Increase his activity before he goes to bed, so he eventually falls asleep from being tired.
- C. Give him a favorite cuddly animal or a blanket.
- D. Allow him to stay up an hour later with the family until he falls asleep.
Correct Answer: C
Rationale: A comfort object helps a toddler feel secure and supports self-soothing.
A three-year-old is brought into the emergency department in her mother's arms. The child's mouth is open and she is drooling and lethargic. Her mother states that she became ill suddenly within the past 2 hours. What should the nurse do first?
- A. Draw blood cultures for complete blood count.
- B. Start an intravenous line.
- C. Inspect the child's throat with a tongue blade.
- D. Maintain the child in an undisturbed, upright position.
Correct Answer: D
Rationale: The symptoms suggest possible epiglottitis, a medical emergency. Maintaining the child in an undisturbed, upright position prevents airway obstruction and is the priority action.
The nurse is explaining the nature of the fracture to the parents of a 10-year-old who has a greenstick fracture. Which drawing should the nurse choose to explain the fracture to the parents?
- A. fracture-1.png
- B. fracture-2.png
- C. fracture-3.png
- D. fracture-4.png
Correct Answer: C
Rationale: A greenstick fracture involves an incomplete break, typically shown as a bend or partial break in the bone, common in children due to their flexible bones.