TB-Chapter 22 Health Care Adaptations for the Child and Family.

1. What is the best pulse location for the nurse to use when assessing the pulse rate on a 12-month-old infant? a. Brachial b. Apical c. Radial d. Femoral ANS: B Apical pulses are advised for children under age 5 years. DIF: Cognitive Level: Knowledge REF: Page 502 TOP: Physical Assessment KEY: Nursing Process Step: Data Collection MSC: NCLEX: Physiological Integrity: Physiological Adaptation 2. The nurse preparing to administer medication to a 2-month-old infant discovers there is no ID bracelet on the child. What should be the next action by the nurse? a. Give the medication after confirming the childs name from the foot of the crib. b. Ask the charge nurse to give the medicine. c. Confirm the identity with the charge nurse, make a new bracelet, and give the medicine. d. Delay the medication until the admissions office can supply a new ID bracelet. ANS: C After confirmation of the childs identity with the charge nurse and making a new bracelet, the medication can be safely given. All patients should be identified before treatment. DIF: Cognitive Level: Application REF: Page 497 OBJ: 2 TOP: ID Bracelets KEY: Nursing Process Step: Implementation MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control