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A nurse in the emergency department is caring for a 2-yr old child who was found by his parents
crying and holding a container of toilet bowl cleaner. The child's lips are edematous and
inflamed, and he is drooling. Which of the following is the following priority action by the
nurse?
a. Remove the child's contaminated clothing.
b. Check the child's respiratory status.
c. Administer an antidote to the child.
d. Establish IV access for the child. - (answer)b. Check the child's respiratory status.
Rationale: 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 change to occur.
A nurse is teaching a parent of a 12-month old child about development during the toddler years.
Which of the following statements should the nurse include?
a. Your child should be referring to himself using the appropriate pronoun by the 18 months of
age
,b. a toddler's interest in looking at pictures occurs at 20 months of age
c. a toddler should have daytime control of his bowel and bladder by 24 months of age.
d. your child should be able to scribble spontaneously using a crayon at the age of 15 months -
(answer)d. your child should be able to scribble spontaneously using a crayon at the age of 15
months
Rationale: The nurse should teach the parent that at the age of 15 months, the toddler should be
able to scribble spontaneously, and at the age of 18 months, the toddler should be able to make
strokes imitatively
A nurse is caring for a toddler and is preparing to administer 0.9% sodium chloride 100ml IV to
infuse over 4 hr. The drop factor of the manual IV tubing is 60 gtt/ml. The nurse should set the
manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole
number) - (answer)25 gtt
Rationale: 100ml/4 hr x 60gtt/1mlx 1 hr/60min= 6000/240= 25 gtt
A nurse in a pediatric clinic is assessing a toddler at a well-child visit. Which of the following
actions should the nurse take?
a. Perform the assessment in a head to toe sequence.
b. Minimize physical contact with the child initially.
c. Explain procedures using medical terminology
,d. Stop the assessment if the child becomes uncooperative. - (answer)b. Minimize physical
contact with the child initially.
Rationale: The nurse should initially minimize physical contact with the toddler, and then
progress from the least traumatic to the most traumatic procedures.
A nurse is caring for an 18-yr old adolescent who is up to date on immunizations and is planning
to attend college. The nurse should inform the client that he should receive which of the
following immunizations prior to moving into a campus dormitory.
a. Pneumococcal polysaccharide
b. Meningococcal polysaccharide
c. rotavirus
d. Herpes zoster - (answer)b. Meningococcal polysaccharide
Rationale: The meningococcal polysaccharide immunization is used to prevent infection by
certain groups of meningococcal bacteria. Meningococcal infection can cause life-threatening
illnesses, such as meningococcal meningitis, which affects the brain, and meningococcemia,
which affects the blood. Both of these conditions can be fatal. College freshmen, particularly
those who live in dormitories, are at an increased risk for meningococcal disease relative to other
persons their age. Therefore, the Centers for Disease Control and Prevention has issued a
recommendation that all incoming college students receive the meningococcal immunization.
, A nurse is teaching the parent of an infant about food allergens. Which of the following foods
should the nurse include as being the most common food allergy in children.
a. Cow's milk
b. Wheat bread
c. Corn syrup
d. Eggs - (answer)a. Cow's milk
Rationale: According to evidence-based practice, the nurse should instruct the parent that cow's
milk is the most common food allergy in children. Some children are sensitive to the protein,
called casein, found in cow's milk. They have difficulty metabolizing the casein and are,
therefore, allergic to cow's milk.
A nurse is teaching the parent of a toddler about home safety. Which of the following statements
by the parent indicates an understanding of the teaching?
a. I lock my medications in the medicine cabinet
b. I keep my child's crib mattress at the highest level
c. I turn pot handles to the side of my stove while cooking.
d. I will give my child syrup of ipecac if she swallows something poisonous. - (answer)a. I lock
my medications in the medicine cabinet