answers
A preschooler has a small laceration that required 2 stitches. The nurse covers the wound with a
bandage knowing that it will comfort the child to have it covered. What is the developmental
reason for this intervention. correct answer Preschoolers are magical thinkers and imagine
bandages keep their insides from coming out.
A 7-month old presents to the ED with a complaint of fever. Assessment reveals a patent airway
and a slight cyanosis around his lips and nail beds. He is alert and interactive. His vital signs are
38.5 (101.3), HR 134, RR 32, BP 78/54 mm Hg, and SPO2 of 84%. The nurse notes a healed
surgical scar on his chest.Based on this assessment, what is the nurse's priority? correct
answer As if the SPO2 is normal for him.
An 11-year-old presents to the ED with a complaint of hitting his head while playing soccer. The
nurse enters the room and performs an across the room assessment. He is starting at the wall. He
has no increased work of breathing and his color is pink. Using the PAT what classification will
the nurse assign? correct answer Sicker
The pediatric prioritization process components include the focused assessment, focused history,
acuity rating decision and: correct answer The pediatric assessment triangle (PAT)
A 2-year-old is brought to the ED by her father when he found her face down in the pool. She
remains unresponsive and is breathing shallowly and slowly. Her color is pale. What is the
priority? correct answer Immobilize the cervical spine
A 2-year-old has a suspected cervical spinal injury. In order to ensure neutral spinal alignment,
padding should be placed under which area? correct answer The shoulders.
Test the Ph of the gastric contents. correct answer The nurse is preparing to administer a
feeding through an NG tube. The tube position was verified by radiograph after insertion 2 hours
ago. What is the best way to verify placement before feeding?