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Which of the following is an appropriate action for the nurse to take to deliver atraumatic care?
- A. Apply eutectic mixture of local anesthetics (EMLA) cream immediately before the injections.
- B. Provide a pacifier coated with an oral sucrose solution prior to the injections.
- C. Inject the immunizations into the deltoid muscle.
- D. Use a 20-gauge needle for the injections.
Correct Answer: B
Rationale: The correct answer is B: Provide a pacifier coated with an oral sucrose solution prior to the injections. This is an appropriate action for atraumatic care because it helps to reduce pain and distress during procedures, such as injections, by utilizing non-pharmacological comfort measures. The sucrose solution on the pacifier helps to soothe and distract the child, making the experience less traumatic.
Choice A (Apply EMLA cream immediately before injections) is incorrect because while EMLA cream numbs the skin, it does not address the psychological aspect of pain and distress associated with procedures.
Choice C (Inject the immunizations into the deltoid muscle) is incorrect because the location of injection does not directly relate to atraumatic care.
Choice D (Use a 20-gauge needle for the injections) is incorrect because the size of the needle does not address the psychological comfort of the child during the procedure.
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Which of the following statements should the nurse make?
- A. An alarm will sound if your child has an abnormal heart rhythm.
- B. Leads will be placed on your child's back prior to the procedure.
- C. This procedure will take at least 30 minutes to complete.
Correct Answer: B
Rationale: The correct answer is B because leads are typically placed on the back before a procedure like an electrocardiogram (ECG) to monitor the heart's electrical activity. This step is crucial for obtaining accurate results. Choice A is incorrect as alarms are not typically used during ECGs. Choice C is incorrect because the duration of the procedure can vary and is not necessarily 30 minutes. Choices D, E, F, and G are blank, so they do not provide any relevant information.
Complete the following sentence by using the list of options. The nurse should first----- followed by -------
- A. Teach the child's parents the importance of inspecting the child's play area.
- B. Obtain informed consent.
- C. Monitor the child closely for return of gag reflex.
- D. Encourage the parents to inspect toys for easily removable parts.
- E. keep the child NPO
- F. prepare the child for flexible endoscopy
Correct Answer: E,F
Rationale: The correct answer is E, F. Firstly, keeping the child NPO (nothing by mouth) is essential before a flexible endoscopy to prevent aspiration during the procedure. Secondly, preparing the child for the flexible endoscopy involves informing them about the procedure and ensuring they are physically and emotionally ready. Choice A is incorrect as it does not directly relate to the procedure; B is not the immediate priority before the endoscopy; C is important post-procedure, not first; D is relevant but not the initial step.
Which of the following safety measures should the nurse include in the teaching?
- A. Check clothing for loose buttons.
- B. Adjust the water heater temperature to 54° C (129.2° F).
- C. Place screens on all windows.
- D. Provide balloons for play.
Correct Answer: A
Rationale: The correct answer is A: Check clothing for loose buttons. This safety measure is important to prevent choking hazards in children. Loose buttons can easily come off and be swallowed. B is incorrect as the recommended water heater temperature is 49°C (120°F) to prevent scalding. C is irrelevant to the safety of a child's clothing. D is incorrect as balloons pose a choking hazard.
The nurse should identify which of the following findings as a potential indicator of physical abuse?
- A. Front deciduous teeth missing
- B. Weight in 45th percentile
- C. Bruising around the wrists
- D. Abrasions on the knees
Correct Answer: C
Rationale: The correct answer is C, bruising around the wrists. This is indicative of physical abuse as it suggests grabbing or restraining. Front deciduous teeth missing (A) is more likely due to normal tooth loss. Weight in 45th percentile (B) is within a healthy range. Abrasions on the knees (D) are common in children.
A nurse in an emergency department is caring for a 3-month-old infant. Which of the following actions should the nurse take?
- A. Administer ceftriaxone.
- B. Administer pneumococcal conjugate vaccine.
- C. Initiate serum glucose testing every 1 hr.
- D. Initiate neutropenic precautions.
Correct Answer: A
Rationale: The correct answer is A: Administer ceftriaxone. In infants, ceftriaxone is commonly used for treating bacterial infections due to its broad-spectrum coverage. It is important to initiate prompt treatment in infants to prevent complications. Administering a pneumococcal conjugate vaccine (choice B) is important for prevention but not an immediate action in this scenario. Initiating serum glucose testing every 1 hr (choice C) is not necessary unless there are specific indications, as it may cause unnecessary stress to the infant. Neutropenic precautions (choice D) are not relevant in this case as there is no indication of neutropenia.