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Which of the following children would the nurse identify as a priority for having the greatest risk for choking and suffocating?
- A. A toddler playing with his 9-year-old brother's construction set.
- B. A 5-year-old eating yogurt for a snack.
- C. An infant asleep in her crib without a blanket.
- D. A 3-year-old drinking a glass of juice.
Correct Answer: A
Rationale: A toddler playing with small construction set pieces is at high risk for choking due to the size and accessibility of the objects.
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The nurse is reviewing the labs of a child who has recently had oral surgery. Which of the following lab results should the nurse pay the closest attention to?
- A. BUN level
- B. Prothrombin time
- C. Creatinine level
- D. Viral load
Correct Answer: B
Rationale: Prothrombin time assesses clotting, critical post-oral surgery to monitor bleeding risk. BUN and creatinine assess kidney function, and viral load is irrelevant.
The nurse is planning to perform a dressing change for a client with a stage three pressure injury. The nurse should initially perform which action?
- A. Gather all the necessary equipment
- B. Use non-sterile gloves to remove the old dressing
- C. Document the characteristics of the wound
- D. Administer prescribed oral pain medication
Correct Answer: A
Rationale: Gathering equipment ensures efficiency and sterility. Non-sterile gloves, documentation, and pain medication follow preparation.
The nurse is caring for a client who has generalized urticaria. Which disease transmission precautions should the nurse implement?
- A. Airborne precautions
- B. Droplet precautions
- C. Contact precautions
- D. Standard precautions
Correct Answer: D
Rationale: Generalized urticaria is typically non-infectious (e.g., allergic), requiring only standard precautions. Transmission-based precautions are unnecessary.
The nurse is caring for a client with a port. Which of the following actions would be appropriate to take? Select all that apply.
- A. Access the port using sterile technique.
- B. Flush the port with heparin prior to de-access.
- C. Access the port using a 16-gauge catheter.
- D. Have the client wear a mask during the dressing change.
- E. Aspirate for blood return prior to medication administration.
Correct Answer: A,B,E
Rationale: Sterile technique, heparin flushing, and aspirating for blood return are standard for port care. A 16-gauge catheter is too large, and a client mask is unnecessary.
The nurse is caring for a child immediately postoperative following a left ear myringotomy. The nurse should position the child
- A. left lateral recumbent
- B. prone
- C. right lateral recumbent
- D. modified trendelenburg
Correct Answer: C
Rationale: Positioning the child on the right lateral recumbent side (operative ear up) post-myringotomy facilitates drainage from the left ear and prevents pressure on the surgical site. Left lateral recumbent or prone positions could obstruct drainage, and modified Trendelenburg is not indicated.