NCLEX Fundamental Critical Care Child Health The practical nurse monitoring a 3-year..(Chancelor)/The practical nurse monitoring a 3-year-old finds
... [Show More] dyspnea, high fever, irritability, and openmouthed drooling with leaning forward. The parents report that the symptoms started rather
abruptly. The client has not received age-appropriate vaccinations. Which set of actions should
the practical nurse anticipate?
1.
20-gauge needle insertion at the mid-axillary line for pleural aspiration
2.
4 L oxygen at 100% per nasal cannula with bilevel positive airway pressure ventilation
standing by
3.
Intubation in the operating room with a prepared tracheotomy kit standing by
4.
Nebulized racemic epinephrine with a pediatric anesthesiologist standing by
Correct answer 3
2. A nurse is caring for a school-age client with fever, somnolence, and a skin rash from
suspected meningococcal meningitis. Which of the following interventions should the nurse plan
to implement for this client? Select all that apply.
1.
Elevate head of bed at 30 degrees
2.
Implement seizure precautions
3.
Keep a mask on the client at all times
4.
Minimize environmental stimuli
5.
Place client in a room with negative-pressure air flow
Correct answer 1,2,4
3. A 3-month-old client has stopped breathing. Identify the area where the nurse should check
the client's pulse. Left-clicking the mouse will place an X to show the answer before
submitting the question.
Correct answer Refer to Hotspot.
4. The home health nurse is providing care for a 6-year-old client who has a tracheostomy and is
being mechanically ventilated when the ventilator's apnea alarm sounds. The nurse finds the
client to be unresponsive and pulseless, and there are no other caregivers present. Which action
should the nurse take first?
1.
Begin chest compressions
2.
Deliver 2 breaths using a bag valve device connected to the tracheostomy
3.
Locate and apply an automated external defibrillator
4.
Use a phone to call 911
Correct answer 1
5. A client with right-sided weakness becomes dizzy, loses balance, and begins to fall while the
nurse is assisting with ambulation. Which nursing actions would best prevent injury to the client
and nurse while guiding the client to a horizontal position on the floor?
1.
Step behind client with arms around waist, squat using the quadriceps, and lower client to
the floor
2.
Step in front of client, brace knees and feet against the client's, and assist to the floor
gently
3.
Step slightly behind client with feet apart, extend one leg, and let client slide against it to
the floor
4.
Step 12 inches behind the client, support under axillae, tighten back, and lower client to
the floor
Correct answer 3
6. A home health nurse is reinforcing teaching with the spouse of an elderly client who
experienced a stroke regarding ways to reduce risk for falls in the home. Which suggestion by
the spouse would be the most effective plan to prevent falls?
1.
Have a respite caregiver come once a week to stay with the client so the spouse can go
shopping
2.
Purchase a walker for the client to use when ambulating around the home
3.
Remove all area rugs and install grab bars in the bathroom
4.
Take the client for an annual eye exam and new glasses
Correct answer 3 [Show Less]