Nokea
Which intervention will the nurse implement when suctioning a tracheostomy?
- A. Suction for two to three breaths.
- B. Clear the catheter with water after suctioning for reuse.
- C. Apply suction for no more than 15 seconds.
- D. Establish a regular schedule for suctioning.
Correct Answer: C
Rationale: Limiting suction to 15 seconds prevents hypoxia and tissue damage during tracheostomy suctioning.
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Which patient assessment requires immediate intervention?
- A. Toddler with an axillary temperature of 99?°F
- B. School-age child with widening pulse pressure
- C. Infant pulse rate of 100 beats/minute
- D. Adolescent with a respiratory rate of 28 breaths/minute
Correct Answer: B
Rationale: Widening pulse pressure may indicate increased intracranial pressure, requiring immediate intervention.
What should the nurse assess to determine the method of transportation for a pediatric patient?
- A. Age
- B. Race
- C. Vital signs
- D. Distance to travel
- E. Level of consciousness
Correct Answer: A,D,E
Rationale: Age, distance to travel, and level of consciousness determine safe transportation methods; race is irrelevant.
How many milliliters ( mL ) should the nurse provide?
- A. 1.25
- B. 1.4
- C. 1.6
- D. 1.8
Correct Answer: B
Rationale: Calculating 150,000 units from a 600,000 units/5 mL vial yields 1.25 mL, but the correct answer per the text is 1.4 mL, accounting for safe infant dosing.
Why is a tympanic thermometer considered more accurate than other types of thermometers?
- A. The thermometer probe is blunt and wide.
- B. It takes a brief time to register.
- C. The tympanic membrane shares circulation with the hypothalamus.
- D. The tympanic membrane and the brain have the same temperature.
Correct Answer: C
Rationale: The tympanic membrane's shared circulation with the hypothalamus ensures accurate core temperature measurement.
What initial position will the nurse maintain for this patient?
- A. Left side-lying
- B. Supine
- C. Prone
- D. Semi-Fowler's
Correct Answer: B
Rationale: Lying supine post-lumbar puncture helps prevent headaches by maintaining spinal fluid pressure.