Answers
A preschooler has a small laceration that required 2 stitches. The nurse covers the wound with a bandage
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knowing that it will comfort the child to have it covered. What is the developmental reason for this
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intervention?
A. Preschoolers are magical thinkers and imagine bandages keep their insides from coming out
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B. Preschoolers fear physical disability and believe a bandage will prevent disability
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C. Preschoolers explore orally and will likely chew or suck on the stitches if left uncovered
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D. Preschoolers are concerned with body image and don't want to appear different than peers - correct
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answers
A 7-month-old presents to the emergency department with a complaint of fever. Assessment reveals a patent
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airway and slight cyanosis around his lips and nail beds. He is alert and interactive. His vital signs are 38.5 °C
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(101.3 °F), HR 134, RR 32, BP 78/54 mm Hg, and SpO2 84%. The nurse notes a healed surgical scar on his chest.
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Based on this assessment, what is the nurse's priority?
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A. Administer ibuprofen to treat the fever
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B. Begin oxygen via a nonrebreather mask
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C. Obtain a surgical history
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D. Ask if the SpO2 is normal for him - correct answers
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An 11-year-old presents to the emergency department with a complaint of hitting his head while playing
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soccer. The nurse enters the room and performs an across-the-room assessment. He is staring at the wall. He
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, has no increased work of breathing, and his color is pink. Using the pediatric assessment triangle (PAT), what
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classification will the nurse assign? l l l l
A. Well l
B. Sick
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C. Sicker
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D. Sickest - correct answers
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The pediatric prioritization process components include the focused assessment, focused history, acuity
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rating decision and: l l
A. the pediatric assessment triangle (PAT).
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B. developmental characteristics.
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C. head-to-toe assessment.
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D. life-saving interventions. - correct answers
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A 2-year-old is brought to the emergency department by her father when he found her face down in the pool.
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She remains unresponsive and is breathing shallowly and slowly. Her color is pale. What is the priority?
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A. Administer 100% oxygen
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B. Immobilize the cervical spine
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C. Begin bag-mask ventilation
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D. Insert an oral airway - correct answers
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A 2-year-old has a suspected cervical spinal injury. In order to ensure neutral spinal alignment, padding should
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be placed under which area?
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A. Shoulders
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B. Head
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C. Neck
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D. Waist - correct answers
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The nurse is preparing to administer a feeding through a nasogastric feeding tube. The tube position was
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verified by radiograph after insertion 2 hours ago. How will the nurse verify placement before feeding?
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