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RN LEARNING SYSTEM NURSING CARE OF CHILDREN PRACTICE QUIZ 2 QUESTIONS AND ANSWERS 2024
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RN LEARNING SYSTEM NURSING CARE OF CHILDREN PRACTICE QUIZ 2 QUESTIONS AND ANSWERS 2024
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RN LEARNING SYSTEM NURSING CARE OFCHILDREN PRACTICE QUIZ 2
A nurse is caring for a child who is in skeletal traction. Which of the following
actions is the nurse's priority? - ANSWERS-Encourage the child to use an incentive
spirometer.
--The nurse should apply the ABC priority-setting framework. This framework
emphasizes the basic core of human functioning - having an open airway, being
able to breathe in adequate amounts of oxygen, and circulating oxygen to the
body's organs via the blood. An alteration in any of these can indicate a threat to
life, and is therefore the nurse's priority concern. When applying the ABC priority
setting framework, airway is always the highest priority because the airway must
be clear and open for oxygen exchange to occur. Breathing is the second highest
priority in the ABC priority setting framework because adequate ventilatory effort
is essential in order for oxygen exchange to occur. Encouraging the child to use an
incentive spirometer will assist the child in adequate oxygenation and is the
priority nursing action. Circulation is the third highest priority in the ABC priority
setting framework because delivery of oxygen to critical organs only occurs if the
heart and blood vessels are capable of efficiently carrying oxygen to them.
A nurse in an emergency department is caring for a toddler who is in acute
respiratory distress. Which of the following findings should alert the nurse to the
possibility of epiglottitis? - ANSWERS-Drooling
,--Epiglottitis is a disorder caused by an inflammation of the epiglottis. It results in
rapid swelling of the epiglottis, which can obstruct breathing. Drooling is common
finding due to the toddler's inability to swallow saliva.
A nurse is teaching a school-age child and his parents how to self-administer
insulin. Which of the following actions should the nurse take first? - ANSWERS-
Demonstrate the injection technique on an orange.
--The nurse should apply the safety and risk reduction priority setting framework.
This framework assigns priority to the factor or situation posing the greatest
safety risk to the client. When there are several risks to client safety, the one
posing the greatest threat is the highest priority. Demonstrating the injection
technique on an orange poses no risk to the client and is therefore the first action
the nurse should take. The nurse should use Maslow's hierarchy of needs, the
ABC priority setting framework, or nursing knowledge to identify which risk poses
the greatest threat to the client.
A nurse is caring for an 8-year-old who has acute glomerulonephritis. Which of
the following findings should the nurse expect? - ANSWERS-Periorbital edema
--Periorbital edema is an expected finding in a child who has glomerulonephritis.
A nurse in an emergency department is assessing a school-age child who is
experiencing an acute asthma exacerbation. Which of the following findings is the
priority for the nurse to report to the provider? - ANSWERS-Sudden decrease in
wheezing
, --The nurse should apply the urgent versus nonurgent priority setting framework.
Using this framework, the nurse should consider urgent needs the priority need
because they pose a larger risk to the client. A sudden decrease in wheezing can
be an indication that the child is experiencing decreased air movement and
should be reported to the provider. The nurse might also need to use Maslow's
hierarchy of needs, the ABC priority setting framework, or nursing knowledge to
identify which finding is the most urgent. A sudden decrease in wheezing (silent
chest) indicates ventilator failure and an imminent respiratory arrest.
A nurse is admitting a child who has Wilms' tumor. Which of the following actions
should the nurse take? - ANSWERS-Put a "no abdominal palpation" sign over the
child's bed.
--The nurse should place a sign over the child's bed reading "no abdominal
palpation" because palpation is not necessary to confirm diagnosis and could aid
in metastasis.
A nurse is caring for a child who has a possible intussusception. The parents of the
child ask the nurse how the diagnosis is made. Which of the following responses
should the nurse make? - ANSWERS-"An abdominal ultrasound will confirm the
pocket in the intestine."
--Intussusception is the invasion of one part of the intestine into the other,
creating a pocket. The presence of an intussusception is confirmed by an
abdominal x-ray, ultrasound, or CT scan.
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