Nokea
The pediatric nurse receives report on 4 clients. Which client should the nurse see first?
- A. A 2-month-old awaiting evaluation for possible hip dislocation; parents are at the bedside
- B. A 6-year-old just returned from a bronchoscopy; a parent is at the bedside
- C. A 7-year-old just returned from a non-contrast abdominal CT scan; no parents are at the bedside
- D. An 11-year-old scheduled for ear surgery today, no parents are at the bedside
Correct Answer: B
Rationale: The 6-year-old post-bronchoscopy is at risk for airway complications and requires immediate assessment.
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A child who ingested 15 maximum strength acetaminophen tablets 45 minutes ago is seen in the emergency department. Which of these orders should the registered nurse implement first?
- A. Gastric lavage PRN
- B. Antidote N-acetylcysteine (NAC) (Mucomyst) for age per pharmacy
- C. Start an IV Dextrose 5% with 0.33% normal saline to keep vein open
- D. Activated charcoal per pharmacy
Correct Answer: A
Rationale: Gastric lavage PRN. Removing as much of the drug as possible is the first step in treatment for this drug overdose. This is best done by gastric lavage. The next actions to complete would be to administer activated charcoal, then Mucomyst and lastly the IV fluids.
The nurse is observing client care situations. Which of the following situations would require an order for physical restraints? Select all that apply.
- A. A long leg immobilizer is used for a client with a fractured tibia.
- B. A mummy restraint is used for an infant while the nurse obtains a blood specimen.
- C. Full padded side rails are placed in the raised position for a client who is experiencing a seizure.
- D. A belt restraint is used for a client with confusion who is on bed rest but continually attempts to get out of the bed.
- E. A soft ankle restraint is used to prevent bleeding at the femoral site for a client who had a cardiac catheterization and is drowsy.
Correct Answer: D,E
Rationale: Belt and ankle restraints require a provider's order due to their restrictive nature. Immobilizers, mummy restraints, and padded rails are typically used for specific purposes without restraint orders.
A hearing-impaired client is becoming withdrawn and depressed. He reports that even with a hearing aid, he is having increased difficulty hearing. Which suggestion is least likely to be helpful?
- A. Get a hearing guide dog.
- B. Join a social club.
- C. Get a telephone TDD.
- D. Get a closed-caption TV.
Correct Answer: A
Rationale: A hearing guide dog is less helpful for communication compared to social engagement, TDD, or closed-caption TV, which directly address hearing loss.
An adolescent client is admitted in respiratory alkalosis following aspirin overdose. The nurse recognizes that this imbalance was caused by
- A. Tachypnea
- B. Acidic byproducts
- C. Aspirin poisoning and dehydration
- D. Hyperpyrexia
Correct Answer: A
Rationale: Tachypnea. Stimulation of respiratory center leads to hyperventilation, thus decreasing CO2 levels which causes respiratory alkalosis.
The nurse is reinforcing instructions to a client on collection of a sputum specimen for culture and sensitivity. Which of the following client statements indicate that teaching has been effective? Select all that apply.
- A. I should rinse my mouth with water before collecting the sputum.
- B. I will be careful not to touch the inside of the specimen cup or lid.
- C. I will inhale deeply a few times and then cough forcefully.
- D. It is best to collect the sputum mid-day when my secretions are loose.
- E. It is helpful if I am sitting upright when I collect the sputum.
Correct Answer: A,B,C,E
Rationale: Rinsing the mouth, avoiding contamination, deep coughing, and sitting upright ensure a quality specimen. Morning collection is preferred for higher yield.