A 12-month-old boy is admitted with a respiratory infection and possible pneumonia. He is
placed in a mist tent with oxygen. Which nursing intervention has the greatest priority for this
infant?
Give small, frequent feedings of fluids.
Accurately chart observations regarding breath sounds.
Have a bulb syringe readily available to remove secretions.
Encourage older siblings to visit. - CORRECT ANSWER - Have a bulb syringe readily available
to remove secretions.
A patent airway has the highest priority. Humidification will liquefy the nasal secretions
thereby increasing the amount of secretions and making (C) the highest priority. (A) maintains
,hydration and prevent tiring, but an open airway has a higher priority! (B) is important for
evaluation of therapy. When asked "priority" questions, REMEMBER MASLOW! Physical needs
usually have a higher priority than psychosocial needs (D) and an open airway is the highest
physiological need!
A 14-year-old female client tells the nurse that she is concerned about the acne she has
recently developed. Which recommendation should the nurse provide?
Remove all blackheads and follow with an alcohol scrub.
Use medicated cosmetics only to help hide the blemishes.
Wash the hair and skin frequently with soap and hot water.
Encourage her to see a dermatologist as soon as possible. - CORRECT ANSWER - Wash the
hair and skin frequently with soap and hot water.
Washing the hair and skin with soap and hot water (C) removes oil and debris from the skin and
helps prevent and treat acne. Oily skin is especially bothersome during adolescence when
,hormones cause enlargement of sebaceous glands and increased glandular secretions which
predispose the teenager to acne. (A) is contraindicated. Cosmetics ("medicated" or not) should
be used sparingly to avoid further blocking sebaceous gland ducts (B). (D) might be indicated at
a later time, if healthcare recommendations are not successful.
A 15-year-old girl tells the school nurse that all of her friends have started their periods and she
feels abnormal because she has not. Which response is best for the nurse provide?
Refer the adolescent to the healthcare provider for a pregnancy screen.
Schedule a conference with her parents to recommend hormone therapy.
Explain that menarche varies and occurs between the ages of 12 and 18 years.
Suggest that she use diversions to help her not worry about delayed menarche. - CORRECT
ANSWER - Explain that menarche varies and occurs between the ages of 12 and 18 years.
The nurse should provide a factual and reassuring explanation that focuses on individual
variations of menarche, which can normally occur between 12 and 18 years of age (C). (A) does
not address the adolescent's concern and is judgmental. Menarche is influenced by hereditary,
, general health, and nutritional status, so (B) is not indicated. (D) dismisses the adolescent's
concerns and does not offer factual information.
A 16-year-old is brought to the Emergency Center with a crushed leg after falling off a horse.
The adolescent's last tetanus toxoid booster was received eight years ago. What action should
the nurse take?
Dispense a tetanus antitoxin.
Prepare human tetanus immune globulin.
Administer tetanus toxoid booster.
Delay the tetanus toxoid booster until due. - CORRECT ANSWER - Administer tetanus toxoid
booster.
After the completion of the initial tetanus immunization schedule, the recommended booster
for an adolescent or adult is every ten years or less if a traumatic injury occurs that is
contaminated by dirt, feces, soil, or saliva, such as puncture or crushing injuries, avulsions,
wounds from missiles, burns, or frostbite. The adolescent's injury is considered a contaminated
placed in a mist tent with oxygen. Which nursing intervention has the greatest priority for this
infant?
Give small, frequent feedings of fluids.
Accurately chart observations regarding breath sounds.
Have a bulb syringe readily available to remove secretions.
Encourage older siblings to visit. - CORRECT ANSWER - Have a bulb syringe readily available
to remove secretions.
A patent airway has the highest priority. Humidification will liquefy the nasal secretions
thereby increasing the amount of secretions and making (C) the highest priority. (A) maintains
,hydration and prevent tiring, but an open airway has a higher priority! (B) is important for
evaluation of therapy. When asked "priority" questions, REMEMBER MASLOW! Physical needs
usually have a higher priority than psychosocial needs (D) and an open airway is the highest
physiological need!
A 14-year-old female client tells the nurse that she is concerned about the acne she has
recently developed. Which recommendation should the nurse provide?
Remove all blackheads and follow with an alcohol scrub.
Use medicated cosmetics only to help hide the blemishes.
Wash the hair and skin frequently with soap and hot water.
Encourage her to see a dermatologist as soon as possible. - CORRECT ANSWER - Wash the
hair and skin frequently with soap and hot water.
Washing the hair and skin with soap and hot water (C) removes oil and debris from the skin and
helps prevent and treat acne. Oily skin is especially bothersome during adolescence when
,hormones cause enlargement of sebaceous glands and increased glandular secretions which
predispose the teenager to acne. (A) is contraindicated. Cosmetics ("medicated" or not) should
be used sparingly to avoid further blocking sebaceous gland ducts (B). (D) might be indicated at
a later time, if healthcare recommendations are not successful.
A 15-year-old girl tells the school nurse that all of her friends have started their periods and she
feels abnormal because she has not. Which response is best for the nurse provide?
Refer the adolescent to the healthcare provider for a pregnancy screen.
Schedule a conference with her parents to recommend hormone therapy.
Explain that menarche varies and occurs between the ages of 12 and 18 years.
Suggest that she use diversions to help her not worry about delayed menarche. - CORRECT
ANSWER - Explain that menarche varies and occurs between the ages of 12 and 18 years.
The nurse should provide a factual and reassuring explanation that focuses on individual
variations of menarche, which can normally occur between 12 and 18 years of age (C). (A) does
not address the adolescent's concern and is judgmental. Menarche is influenced by hereditary,
, general health, and nutritional status, so (B) is not indicated. (D) dismisses the adolescent's
concerns and does not offer factual information.
A 16-year-old is brought to the Emergency Center with a crushed leg after falling off a horse.
The adolescent's last tetanus toxoid booster was received eight years ago. What action should
the nurse take?
Dispense a tetanus antitoxin.
Prepare human tetanus immune globulin.
Administer tetanus toxoid booster.
Delay the tetanus toxoid booster until due. - CORRECT ANSWER - Administer tetanus toxoid
booster.
After the completion of the initial tetanus immunization schedule, the recommended booster
for an adolescent or adult is every ten years or less if a traumatic injury occurs that is
contaminated by dirt, feces, soil, or saliva, such as puncture or crushing injuries, avulsions,
wounds from missiles, burns, or frostbite. The adolescent's injury is considered a contaminated
