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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.
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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.
A home care nurse is providing instructions to the mother of a toddler regarding safety measures in the home to prevent an accidental burn injury. Which statement by the mother indicates a need for further instruction?
- A. I need to use the back burners for cooking.
- B. I need to remain in the kitchen when I prepare meals.
- C. I need to be sure to place my cup of coffee on the counter.
- D. I need to turn pot handles inward and to the middle of the stove.
Correct Answer: C
Rationale: Toddlers, with their increased mobility and developing motor skills, can reach hot water or hot objects placed on counters and open fires or burners on stoves above their eye level. The mother's statement in option 3 does not indicate an adequate understanding of the principles of safety. Hot liquids should never be left unattended, and the toddler should always be supervised. Parents should be encouraged to use the back burners on the stove, remain in the kitchen when preparing a meal, and turn pot handles inward and toward the middle of the stove.
Which situation represents the primary nursing care delivery model?
- A. The registered nurse (RN) performs all tasks needed by the individual client to optimize health.
- B. The RN provides care to 4 clients, while the unlicensed assistive personnel (UAP) is assigned to care for 2 clients.
- C. The RN develops a plan of care for each client and collaborates with other staff members assigned to the same group of clients.
- D. The UAP is assigned to make beds and fill water pitchers. The RN is assigned to administer medications.
Correct Answer: A
Rationale: In primary nursing, option 1, concern is with keeping the nurse at the bedside actively involved in care, providing goal-directed and individualized client care. Option 2 does not follow the guidelines for any specific type of nursing care delivery approach. Team nursing, option 3, is characterized by a high degree of communication and collaboration among members. The team is generally led by an RN, who is responsible for assessing, developing nursing diagnoses, planning, and evaluating each client's plan of care. The functional model of care involves an assembly line approach to client care, with major tasks being delegated by the charge nurse to individual staff members.
A client reporting abdominal pain has a diagnosis of acute abdominal syndrome but the cause has not been determined. Which prescription should the nurse question at this time?
- A. Clear liquid diet only
- B. Insertion of a nasogastric tube
- C. Administration of an analgesic
- D. Insertion of an intravenous (IV) line
Correct Answer: A
Rationale: Until the cause of the acute abdominal syndrome is determined and a decision about the need for surgery is made, the nurse would question a prescription to give a clear liquid diet. The nurse can expect the client to be placed on NPO status and to have an IV line inserted. Insertion of a nasogastric tube may be helpful to provide decompression of the stomach. Pain management with medications that do not alter level of consciousness can decrease diffuse abdominal pain and rigidity, help with localizing the pain, and lead to more prompt diagnosis and treatment.
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.