*Elevate Module 6 Q Review Quiz

What activities would be appropriate for the nurse to delegate to an unlicensed assistive personnel (UAP) caring for a client post-cholecystectomy? Select all that apply 1. Measuring and recording intake and output. 2. Assisting with ambulation in the hallway. 3. Reinforce information about a low fat diet. 4. Assisting with daily hygiene. 5. Monitor and record vital signs. 6. Report increased surgical site pain during ambulation

1., 2., 4., & 6. Appropriate actions for UAPs include measuring and recording I&O, assist with ambulation and hygiene and report to the nurse if the client has pain during activities. 3. Incorrect: Reinforcing teaching can be done by the LPN or RN. 5. Incorrect: Monitoring should be performed by the nurse.

Which client would be appropriate for the charge nurse to assign to a new nurse? 1. Transferred from the intensive care unit after treatment for addisonian crisis. 2. Diagnosed with pheochromocytoma scheduled for an adrenalectomy. 3. Received from the emergency department for observation following a head injury from a motor vehicle accident. 4. Diagnosed with sepsis on admission one day ago.Which client would be appropriate for the charge nurse to assign to a new nurse? 1. Transferred from the intensive care unit after treatment for addisonian crisis. 2. Diagnosed with pheochromocytoma scheduled for an adrenalectomy. 3. Received from the emergency department for observation following a head injury from a motor vehicle accident. 4. Diagnosed with sepsis on admission one day ago.

2. Correct: This client is the most stable of the four clients. The new nurse should be able to care for this client and provide pre-operative teaching. 1. Incorrect: This client was in addisonian crisis and is at risk for developing it again. This client is not the most stable client. 3. Incorrect: This client is not the most stable client of the ones listed. This client should be monitored closely for changes in the neurological status. 4. Incorrect: The client with sepsis is unstable and should not be assigned to the new nurse.

Which infant in the newborn nursery requires an immediate intervention by the nurse? 1. At time of birth, covered with grayish-white cheese-like substance. 2. Three hours old, with quivering of the lower lip. 3. Two hours old, having episodes of apnea lasting 25-30 seconds. 4. One hour old, who has acrocyanosis.

3. Correct. Apnea of greater than or equal to 20-30 seconds in a newborn is indicative of respiratory distress and requires immediate intervention by the nurse. 1. Incorrect. This grayish-white cheese-like substance is vernix caseosa. This is a normal protective covering and does not require immediate intervention by the nurse. 2. Incorrect. Quivering of the lower lip in newborns is a normal finding and indicative of normal reflexes. This does not require intervention by the nurse. 4. Incorrect. Acrocyanosis in the newborn is due to changes in the newborn's peripheral circulation that will improve. This may persist for 24-48 hours and does not require intervention by the nurse.

The nurse admits a client with a C-spine injury to the neuro intensive care unit. The admission assessment is completed. What is the nurse's priority intervention? Exhibit: Nursing Admission Assessment:Client reports blurred vision and a headache rated 9/10. BP 200/110, pulse 55. 1. Reduce air drafts in room 2. Loosen tight clothing 3. Elevate the head of the bed to high fowler's 4. Administer hydralazine

3. Correct: This client is experiencing autonomic dysreflexia! This is a priority question, so what would I do first. Elevate the HOB to decrease the BP. 1. Incorrect: This is a correct answer, but not the priority response. Air drafts may be a stimulus of autonomic dysreflexia and would need to be removed, but if I don't elevate the bed or sit them up first, they could have a hypertensive stroke! 2. Incorrect: This is a correct answer, but not the priority response. If I don't elevate the bed or sit them up first, they could have a hypertensive stroke! 4. Incorrect: This is a correct answer, but not the priority response. Elevating the HOB may lower the BP. If that does not work, then hydralazine may be given.

Which clients would be appropriate for the RN to assign to the LPN? Select all that apply 1. Newly admitted for surgical repair of fractured hip. 2. Diagnosed with severe anemia. 3. Has partial thickness burns over 35% of the body. 4. Diagnosed with cystitis who has been prescribed antibiotics intramuscularly. 5. Needs enemas to decrease bacteria in the GI tract.

4. & 5. Correct: These clients are stable and have a predictable outcome. Caring for them is within the scope of practice for the LPN. 1. Incorrect: This client is not as stable as the other clients and will need assessment and teaching prior to surgery which can only be done by the RN. 2. Incorrect: This client needs to be assessed for signs of hypoxia due to the severe anemia. Also, the client is likely in need of a blood transfusion which is out of the scope of practice for the LPN/VN. 3. Incorrect: This is a complicated client who will have fluid shifts. This client is at risk for fluid volume deficit and is beyond the scope of practice for the LPN.

The pediatric nurse is planning an educational seminar for new parents. The seminar will focus on tips for administering medication to children. Which points should the nurse include? Select all that apply 1. Demonstrate proper measuring techniques for liquid medications. 2. Put crushed medications into the child's favorite food. 3. Place liquid medication in an 8-ounce bottle of formula. 4. Call medication "candy" to encourage children to take the medicine. 5. Do not place medications in a container other than the original container.

1. & 5. Correct: Demonstration with return demonstration by the parent is an appropriate teaching strategy. Give clear examples and demonstrations and speak in layman's terms. Never put medications in dishes, cups, bottles, or other household containers that children or other family members may be unaware of. 2. Incorrect: Do not place crushed drugs into the child's favorite food or snack. The medication can change the taste of the food, and the child may refuse, therefore missing part or all of the dose. Additionally, the effectiveness of some medications may be harmed by the crushing of the drugs. 3. Incorrect: Do not place liquid drugs in a large bottle of formula. Unless the child drinks the entire amount, he or she will not receive the correct dose. 4. Incorrect: Don't refer to drugs as candy. Children may try to take more candy leading to overdose.

A 6 year old admitted from the emergency department (ED) with a fractured tibia is scheduled for surgery in the morning. All of the private rooms are full so the child must be admitted to a semi-private room. What room assignment is appropriate for the nurse to make for this client? 1. Rooming with an 8 year old in sickle cell crisis. 2. Rooming with a 2 year old admitted with bacteremia. 3. Rooming with a 3 year old with pneumonia. 4. Rooming with a 4 year old with gastroenteritis.

1. Correct: Sickle cell disease and a child in a sickle cell crisis is not considered contagious. This is the only option that does not have an infectious process, so this would be the best room assignment for the child with the fracture. In addition, the children are close in age with the same development tasks, so activities for the children may be similar. 2. Incorrect: Bacteremia is an infectious process in which there is viable bacteria in the bloodstream. The source of the infection is not noted. The child with a fracture who will be having surgery should not be placed in a room with a child who has a known infection. 3. Incorrect: The child with pneumonia has an infectious process that may be viral or bacterial. The child with the fracture should not be assigned to this room due to the risk of air-borne exposure to the infectious agent. 4. Incorrect: Gastroenteritis is a diarrheal illness with inflammation in the stomach and small intestine. This is contagious, so if all possible, this child should be kept in a private room, so other children would be less likely to contract the gastroenteritis. It may be viral, bacterial, or parasitic in origin. The child with the fracture should not be assigned to the room with the child with gastroenteritis.

Which nurse would be the most appropriate for the charge nurse to assign to a 5 year old admitted in sickle cell crisis? 1. The nurse who is taking care of a 4 year old who had a routine appendectomy, a 3 year old who had bowel surgery, and a 10 year old with developmental delays. 2. The nurse who is taking care of a 6 month old with Respiratory Syncytial Virus (RSV), a 3 year old with exacerbation of asthma, and a 6 year old with a urinary tract infection for 2 weeks. 3. The nurse taking care of a 9 year old newly diagnosed with diabetes, a 6 year old with end stage renal disease, and a 2 year old with contact dermatitis. 4. The nurse taking care of a 8 year old with skeletal traction, a 5 year old with cerebral palsy, and a 12 year old with cystic fibrosis.

1. Correct: The nurse taking care of the appendectomy, bowel surgery, and developmentally delayed child has the set of clients that is less busy and has fewer client care needs. Routine appendectomy and bowel surgery will need observation and assessment but should be stable. The child with developmental delays will need assistance but no life threatening concerns with any of these clients. 2. Incorrect: This set of clients are not appropriate primarily, because of the RSV client. The client with sickle cell already has an oxygen problem and does not need RSV too. RSV is very contagious. 3. Incorrect: This set of clients are very labor intensive. The newly diagnosed diabetic requires constant assessment and interventions to prevent complications. The 6 year old with end stage renal disease also will require a great deal of nursing assessment. 4. Incorrect: Assignment requires much care for clients. This set of clients are inappropriate because of the labor intensive needs. Skeletal traction will require pin care, skin care and prevention of immobility. The cerebral palsy client will require assistance with hygiene and self care and the cystic fibrosis client requires respiratory and GI care including assessment fro complications.

The nurse is providing care to a client who has a history of violent episodes against his wife. The client has made a specific threat that he plans to kill his wife when he gets out of the hospital. What should the nurse do first? 1. Discuss the threat with the treatment team immediately. 2. Call the wife immediately to report her husband's intention. 3. Do nothing because the client may change his thinking. 4. Tell the client that he shouldn't make threats like that.

1. Correct: Yes, immediately discuss the treat with the treatment team. The duty to warn is an obligation of healthcare providers. The threat should be discussed with the treatment team, and agency policy for notification of the threatened party should be followed. 2. Incorrect: The team should discuss this first; the next action may be to call the wife. At this point, the client is in the hospital and the wife is not in immediate danger. 3. Incorrect: A threat cannot be ignored. The threatened party has the right to know. The treat team will decide and take the appropriate action. 4. Incorrect: The client has reported valuable information and follow up is required.

Which client should the clinic nurse assess first? 1. Client reporting sudden onset of scrotal pain and edema. 2. Client with a history of benign prostatic hypertrophy who is unable to void. 3. Client reporting purulent drainage from the penis. 4. Client who has had an erection for 2 hours.

1. Correct:The client with sudden onset of scrotal pain and edema is likely to have testicular torsion, which requires immediate intervention. Infarction of the testes can occur if not treated promptly. If treated quickly, the testicle can usually be saved. 2. Incorrect: The client with a history of benign prostatic hypertrophy who is unable to void should be assessed next. The client has retention and may need to be catheterized for relief and to prevent renal damage. 3. Incorrect: The third client to be assessed should the one who has purulent drainage, which is a sign of infection. 4 Incorrect: The last client to be assessed would be the client who has a two hour erection. Priapism, a persistent, often painful erection that lasts for more than 4 hours should be treated.

What developmental milestone does the nurse expect to see in a 2 year old toddler? Select all that apply 1. Builds towers of 4 or more blocks. 2. Says sentences with 2 to 4 words. 3. Does puzzles with 3 or 4 pieces. 4. Takes turns in games. 5. Walks up and down stairs holding on. 6. Stands on tiptoe.

1., 2., 5., & 6. Correct: When checking the developmental milestones of a 2 year old, the nurse should expect to see the toddler build a tower of at least 4 blocks, say short sentences of 2-4 words, walk up and down stairs while holding on, and stand on tiptoe. 3. Incorrect: The toddler should be able to complete a 3-4 piece puzzle by age 3. This would not be of concern if a 2 year old is unable to complete this task. 4. Incorrect: The toddler should be able to take turns during a game by age 3. This would not be of concern if a 2 year old does not take turns. A two year old plays mainly beside other children.

What developmental milestones does the nurse expect to see in a 9 month old infant? Select all that apply 1. Looks for fallen object. 2. Follows 1-step verbal command without gestures. 3. Plays peek-a-boo. 4. Understands the word "no". 5. Picks up cereal o's between the thumb and index finger. 6. Stands while holding on to something.

1., 3., 4., 5., & 6. Correct: When looking for the developmental milestones of a 9 month old, the nurse should expect to see the infant look for an object that has been dropped or that the infant sees someone hide. The infant can play simple games like peek-a-boo or itsy-bitsy spider. The word "no" should be understood by this age. Picking up things like cereal o's between the thumb and index finger is the pincer grasp that is achieved at this age. By nine months the infant should be able to pull self to a stand and stand while holding on to something. 2. Incorrect: The infant begins to follow simple directions like "pick up the toy" around the age of 1 year.

Which intervention would the nurse initiate in a 2 year old diagnosed with Sickle Cell Crisis? Select all that apply 1. IV hydration 2. PCA pump for pain relief 3. High flow oxygen 4. Analgesics 5. Antibiotics 6. Strict neutropenic precautions

1., 4., & 5. Correct: The client with Sickle Cell Crisis may be dehydrated. Increasing hydration will improve ability of RBCs to flow through the vascular system. Analgesics are needed for pain control. Infections can precipitate a sickle cell crisis and would need antibiotics to treat the underlying infection. 2. Incorrect: The client is not old enough to manage a PCA pump. 3. Incorrect: Oxygen therapy is not usually indicated unless the client is hypoxic. Oxygen is not helpful in reducing pain or reducing sickling. High flow oxygen can suppress the formation of the needed new red blood cells. 6. Incorrect: Sickle cell clients aren't neutropenic from sickle cell disease. In order to pick an answer like this for a client, the nurse would need to know what the client's ANC (absolute neutrophil count) is. Y'all, what are neutrophils? They are part of the WBC count. So, if a client is on neutropenic precautions, their neutrophil count is low and we are worried about them getting an infection. The client in this scenario has sickle cell disease, so the problem is the RBCs. We would be looking for anemia, not neutropenia.

Following vaginal birth, a neonate has a large area of diffuse swelling over the left occiput that crosses the sagittal suture line. When discussing this finding with the RN in orientation, which statement by the nurse would be accurate? Select all that apply 1. "No treatment will be required to resolve swelling." 2. "Due to the pressure during delivery, bleeding has occurred under the scalp." 3. "The swelling is under the skull bone with bleeding from the brain" 4. "Pressure on the fetal head before delivery caused the swelling." 5. "The infant has a collection of blood under the skull bone, which can cause pressure on the brain."

1.,& 4. Correct: Swelling over the left occiput that crosses the sagittal suture (caput succedaneum) requires no treatment and is caused by pressure on the fetal head before delivery. 2. Incorrect: Caput succedaneum is a collection of serosanguineous fluid, not blood. Cephalohematoma refers to bleeding under the scalp. 3. Incorrect: Caput succedaneum is swelling that overlies the periosteum and is not under the skull bone nor is there bleeding from the brain. 5. Incorrect: Caput succedaneum is a collection of serosanguineous fluid, not blood, and is not under the skull. No pressure is exerted on the brain.

Which condition in children and/or adolescents should a nurse identify as a potential cause of metabolic acidosis? Select all that apply 1. Severe gastroenteritis 2. Diabetes 3. Pyloric stenosis 4. Bulimia nervosa 5. Laxative abuse

1.,2., & 5 Correct: The nurse should identify that gastroenteritis and the diarrhea that accompanies it can lead to metabolic acidosis because of the sodium loss. Laxative abuse seen in anorexia nervosa is the same etiology. Diabetes in children and adolescents is usually Type 1 and is prone to diabetic ketoacidosis. 3. Incorrect: Children diagnosed with pyloric stenosis experience loss of stomach acid from excessive vomiting. The loss of stomach acid (decrease in hydrogen ions) will eventually lead to an increase in blood pH (alkalosis). 4. Incorrect: Children with bulimia nervosa experience loss of stomach acid from excessive vomiting. The loss of stomach acid (decrease in hydrogen ions) will eventually lead to an increase in blood pH (alkalosis).

Which tasks can the RN safely delegate to an LPN when caring for a client scheduled for an adrenalectomy? Select all that apply 1. Compare the fingerstick glucose level for the past 24 hours 2. Administer regular insulin SQ based on sliding scale prescription. 3. Determine if there are any irregularities in the client's cardiac rhythm. 4. Provide teaching regarding postoperative care. 5. Check for completion of the client's pre-surgical laboratory values.

2., & 5. Correct: The LPN can administer SQ injections and check for lab value completion. 1. Incorrect: The LPN can perform the fingerstick but cannot compare the finger sticks results,as that would be evaluation. 3. Incorrect: This would require assessment. The RN must assess, evaluate, and teach. The LPN can collect data to assist the RN, but the RN must validate that the data is correct. The RN assesses cardiac rhythm. 4. Incorrect: The LPN can not provide teaching, the LPN can only reinforce client teaching.

The RN is reviewing client assignments with the LPN working on a medical floor. Which clinical assignment would be appropriate for the LPN? Select all that apply 1. The client with nausea, vomiting, and mild metabolic alkalosis 2. The client with chronic back pain admitted for pain management 3. The client waiting to go to surgery for a scheduled total knee replacement 4. The client with a stage 3 decubitus ulcer requiring a dressing change 5. The client newly diagnosed with Guillain Barre' syndrome

2., 3., & 4. Correct: The LPN can manage pain and can prep someone for the OR. The LPN can also do wound care on a decubitus ulcer. Remember, look at the client where they are here and now. 1. Incorrect: The LPN cannot take care of an unstable client and that includes anyone with an acid base imbalance. 5. Incorrect: The LPN cannot take care of a complicated client. The client newly diagnosed with Guillain Barre' syndrome can have progressing paralysis leading to respiratory failure. This is a complicated and unstable client.

Which signs, if observed in a child, should a clinic nurse associate with Kawasaki disease? Select all that apply 1. Productive cough 2. Strawberry tongue 3. High intermittent fever 4. Enlarged cervical lymph nodes 5. Erythema of the palms and soles

2., 4. & 5. Correct: The nurse should recognize strawberry tongue, high and persistent fever, enlarged cervical lymph nodes, and redness of the palms of the hands and soles of the feet as signs of Kawasaki disease. Kawasaki disease is an autoimmune disease in which the medium-sized blood vessels throughout the body become inflamed. Many organ systems, mainly those including the blood vessels, skin, mucous membranes, and lymph nodes, are affected. The most prominent signs are a high and persistent fever that is not responsive to normal treatment with acetaminophen or ibuprofen, extreme irritability, and the presence of a "strawberry tongue" caused by necrotizing microvasculitis. 1. Incorrect: Coughing is not a typical sign of Kawasaki disease. 3. Incorrect: High persistent fever not intermittent fever is a sign of Kawasaki disease.

The nurse is caring for a client that is 3 days post tonsillectomy and reports a 2 pound (0.91 kg) weight loss, lethargy, and frequent swallowing. What is the nurse's priority assessment? 1. Blood pressure 2. Neuro check 3. Heart rate 4. Breath sounds

3. Correct: This client is in a FVD. The weight has dropped. The blood loss is creating an intravascular volume depletion. So what happens to the heart rate in response to this? The body begins to compensate for the decreased volume by increasing the heart rate and contractility followed by peripheral vasoconstriction in an attempt to perfuse the vital organs. So we know one of the earliest signs of decreased perfusion is tachycardia. However, the body can only compensate for a while. You would then begin to see a drop in the blood pressure as a late sign and tissue perfusion to the vital organs would become more compromised if the blood loss is not controlled and the volume is not restored. 1. Incorrect: SURE, you are going to check the blood pressure. However, if I can only do one of these assessments, I better take the heart rate because that is the one that says SHOCK. Remember, a drop in the blood pressure is a late sign and indicates that the compensatory mechanisms are failing. 2. Incorrect: SURE, you are going to assess the neuro status. However, this is a FVD issue, not a neurological problem. A full neuro check would not be warranted. 4. Incorrect: Breath sounds are very important as well and one of the first assessments we make, BUT if I can only do one of these assessments, I better check the heart rate because that is the one that says SHOCK.

What intervention should the nurse initiate when caring for a child following a tonsillectomy and adenoidectomy? Select all that apply 1. Encourage fluids with a red or brown color. 2. Regular suctioning of the mouth and throat. 3. Administer pain medication around the clock. 4. Apply ice collar to the front of the neck as needed. 5. Avoid coughing and deep breathing every two hours.

3., 4., & 5. Correct: Following tonsillectomy and adenoidectomy, when the child is alert and swallows without difficulty, the nurse should encourage the oral intake of fluids. Also, the nurse would administer pain medication around the clock, and apply an ice collar to the front of the neck if needed. Pain medication, such as acetaminophen with or without codeine, administered at regular intervals controls pain more effectively than PRN administration. An ice collar that is applied to the front of the neck decreases pain as well as the risk for hemorrhage. Coughing should be discouraged as this puts stress on the tonsillectomy site and may cause bleeding. 1. Oral fluid intake prevents dehydration, weight loss, and local infection after surgery but fluids with red or brown color should be discouraged to distinguish fresh or old blood in vomitus. 2. Incorrect: Oral suctioning puts stress on the tonsillectomy site and may cause bleeding. Suctioning is only done as needed and must be performed carefully to avoid trauma.

Which client should the nurse see first? 1. Primigravida on IV magnesium sulfate with deep tendon reflexes of 2+ 2. Multigravida on po terbutaline with a pulse rate of 110/per minute 3. Primigravida on IV oxytocin with contractions every 3-4 minutes 4. Multigravida on po methyldopa with a blood pressure of 142/90.

4. Correct: A systolic blood pressure of ≥ 140 mmHg or a diastolic BP of ≥ 90 mmHg indicates hypertension. This client is already on methyldopa, which is an antihypertensive medication. Her hypertension is worsening and may compromise fetal well being. 1. Incorrect: + DTRs are normal. Clinical signs of safe dosage of magnesium sulfate include normal deep tendon reflexes. Adverse effects include depressed reflexes. 2. Incorrect: Maternal tachycardia (up to 120 bpm) is expected when on this medication. Terbutaline is a beta adrenergic agonist could have significant cardiovascular effects. 3. Incorrect: The desired contraction pattern with oxytocin is 3 in 10 minutes. A contraction every 3-4 minutes would equal 3 contractions in 10 minutes. The dosage of the oxytocin is individualized until the desired contraction rate is achieved.

An unlicensed assistive personnel (UAP) has been assigned to take vital signs on several clients. Which instruction would be most important for the RN to provide to the UAP? 1. "Notify me if the pulse oximetry reading drops below 95% in the client who has emphysema." 2. "The client in room 210 has dizziness and faintness when standing, so I need you to obtain a blood pressure reading with the client in the lying, sitting, and standing position." 3. "The client in room 212 has a pacemaker with a fixed rate of 70 beats/minute. Let me know if the apical heart rate is greater than 70 bpm." 4. "Let me know immediately if any client has a temperature of 101. 5 degrees F (38.6 degrees C) or higher."

4. Correct: A temperature of 101. 5 degrees F (38.6 degrees C) or higher is reported to the primary healthcare provider. The client is likely to need cultures and antibiotic therapy. 1. Incorrect: The client with emphysema will likely have a pulse oximetry reading less than 95%. This is not the most important instruction to give the UAP. 2. Incorrect: This client is likely experiencing orthostatic hypotension, so is unstable. This task should not be assigned to the UAP. The RN should perform this task. 3. Incorrect: The nurse should worry if the heart rate drops below the set pacemaker rate. It is normal for the rate to be greater than the fixed rate, but should never drop below the fixed rate.

A 6 year old child is being cared for on the pediatric unit with a spiral fracture to the right humerus. Bruising and wounds in various stages of healing are noted, and physical abuse is suspected. What action would be appropriate for the nurse to include in the care of this child? Select all that apply 1. Obtain only the narrative of the history of the injury from the parent since the child is a minor. 2. Assure the parents that if they are honest, the information will only be used to care for the child and that it will not be shared with anyone else. 3. Focus on the abuse when identifying nursing care needs for the child. 4. Interact in a positive and constructive manner to the child in front of the parents. 5. Refer the parents to appropriate and available social service agencies. 6. Provide consistent caregivers during the period of hospitalization.

4., 5., & 6. Correct: Should the nurse try to become a substitute parent to the child? Of course not. However, the nurse should serve as a role model for the parents by demonstrating to them how to relate positively and constructively to their child. The nurse can also provide information to the parents regarding physical and emotional needs of children. The parents are often very sensitive to criticism or resistant to authority figures. Demonstration and example rather than through lecturing are best. We all know that not all of the needed care can be accomplished by the nurses and primary healthcare provider. Referral to appropriate social service agencies is also essential. What are some issues that have been found to be associated with child abuse that that social service could be helpful with? One of these is that many abusive parents live in poverty. They often feel overwhelmed by the daily stresses caused by their circumstances. Some of the resources that may need to be sought include financial aid, improved housing, and child care. In addition, parents may find self-help groups to be beneficial. Consistent caregivers help the child re-establish a sense of trust while in the hospital. The child needs an environment that is safe, secure, and where empathy is displayed in order for this trust to be developed. 1. Incorrect: Children who are verbal can often give a history of the injury. But the child may be reluctant to tell the events surrounding the abuse when the parent is present, especially if threats for more harm have been made if the child reports the abuse. So, separating the child from the caregiver may provide a more reliable history. However, the history of the injury should include a report of the injury from both the caregiver and child (if verbal). 2. Incorrect: You should never tell anyone that reports of abuse will be kept confidential. This would not be in the best interest of the child, as it could lead to lack of appropriate care and possible future harm. In addition, the nurse has a legal obligation to report abuse. Even though the laws can vary, all states and provinces in North America have laws for mandatory reporting of child maltreatment. 3. Incorrect: The nurse should recognize the need to promote self-esteem and minimize feelings of guilt by treating the child as having a physical problem, not focusing on the child as an "abused" victim. The child who has been abused still has the same needs as those of any other hospitalized child. The nurse should direct care at meeting the physical needs, promoting attainment of developmental tasks, and incorporating play to minimize the stress of hospitalization.

A nurse is caring for five pediatric clients. In what order should the nurse go to see these clients? Prioritize the clients by placing them in order from first to last. Four year old child with intravenous heparin infusing at a maintenance rate Seven year old child needing a consultation with a certified diabetic educator 12 year old with asthma reporting mild wheezing and receiving Albuterol nebulizer treatments every 4 hours for wheeze and/or cough 5 year old child who is due for an inhalation treatment of ribavirin Ten year old child who has been prescribed intravenous cefoxitin Drag and Drop the items from one box to the other

First, see the 4 year old child with an IV heparin infusion. Heparin is a high alert drug that increases the child's risk for bleeding. Next, the 12 year old with asthma reporting mild wheezing and receiving Albuterol nebulizer treatments every 4 hours for wheeze and/or cough. The nurse would need to assess this child next to ensure that the wheezing does not get worse before the nebulizer treatment is initiated. Ribavirin in an antiviral medication used for severe lower respiratory tract infections. It is not a bronchodilator or respiratory inhaler for opening the airway. The 5 year old child who is due for a breathing treatment soon should be assessed second and given the treatment. The treatment does need to be given on time to prevent respiratory problems due to the illness. The third client to see is the 10 year old child who has been prescribed an intravenous antibiotic. This client is not a high priority. However, the medication will need to be given on time. The 7 year old who needs diabetes education should be assessed fourth or last because the nurse will want to allow time for teaching and return demonstration.

A healthy newborn has just been delivered and placed in the care of the nursery nurse. What nursing actions should the nursery nurse initiate? Administer sterile ophthalmic ointment containing 0.5% erythromycin. Bulb suction excessive mucus. Assess newborn's heart rate. Assess newborn's airway and breathing. Place identification bands on newborn and mom. Drag and Drop the items from one box to the other

The first priority is to assess newborn's airway and breathing. This is done immediately to determine the need for resuscitation or other airway interventions. The infant is positioned in a modified Trendelenburg position in order to facilitate drainage of mucus from the upper airway. Second, bulb suction excessive mucus. This is performed to clear the airway and facilitate the ease of respirations. Third, assess newborn's heart rate. In the absence of respiratory distress, the assessment continues with the vital signs. Heart rate is part of the Apgar scoring of the newborn in which the physical status of the newborn is evaluated at 1 and 5 minutes after birth. The heart rate is the most important aspect of the Apgar scoring. A newborn heart rate that is less than 100 beats/minute is indicative of the need for stimulation and/or resuscitation. Fourth, place identification bands on newborn and mom. The ID bands with identical codes are placed on the mom and the newborn before leaving the delivery room. The band should be applied snugly enough on the newborn to prevent the accidental loss of the band. These must remain on the mom and newborn throughout the hospital stay and discharge. This ensures correct identification and placement of infant with the mom. Fifth, administer sterile ophthalmic ointment containing 0.5% erythromycin. The administration of this eye treatment for Neisseria gonorrhoeae is required by law. However, instilling this medication can be delayed up to 1 hour after birth to facilitate bonding through eye contact between the parent and infant. The other interventions would all precede this.