the mother understands safety precautions with her four month-old
infant and her 4 year-old child?
A) "I strap the infant car seat on the front seat to
... [Show More] face backwards."
B)
"I place my infant in the middle of the living room floor on a
blanket to play with my 4 year old while I make supper in the
kitchen."
C) "My sleeping baby lies so cute in the crib with the little buttocks
stuck up in the air while the four year old naps on the sofa."
D) "I have the 4 year-old hold and help feed the four month-old a
bottle in the kitchen while I make supper."
Review Information: The correct answer is D: "I have the four
year-old hold and help feed the four month-old a bottle in the kitchen
while I make supper." The infant seat is to be placed on the rear seat.
Small children and infants are not to be left unsupervised. Infants are
to be placed on their "back when they go back" to sleep or are lying in
a crib. A 4 year-old could assist with the care of an infant with proper
supervision. This enhances bonding with the infant and the
developmental needs of the preschooler to "help" and not feel left out.
2. Upon completing the admission documents, the nurse learns that
the 87 year-old client does not have an advance directive. What action
should the nurse take?
A) Record the information on the chart
B) Give information about advance directives
C) Assume that this client wishes a full code
D) Refer this issue to the unit secretary
Review Information: The correct answer is B: Give information
about advance directives
For each admission, nurses should request a copy of the current
advance directive. If there is none, the nurse must offer information
about what an advance directive implies. It is then the client’s choice
to sign it. In option 1 just recording the information is not sufficient.
In option 3 the nurse should not assume that the client has been
informed of choices for emergency care. In option 4 this represents an
inappropriate delegation approach.
3. A nurse administers the influenza vaccine to a client in a clinic.
Within 15 minutes after the immunization was given, the client
complains of itchy and watery eyes, increased anxiety, and difficulty
breathing. The nurse expects that the first action in the sequence of
care for this client will be to
A) Maintain the airway
B) Administer epinephrine 1:1000 as ordered
C) Monitor for hypotension with shock
D) Administer diphenhydramine as ordered
Review Information: The correct answer is B: Administer
epinephrine 1:1000 as ordered .All the answers are correct given the
circumstances. The correct sequence of care is to administer the
epinephrine, then maintain airway. In the early stages of anaphylaxis,
when the patient has not lost consciousness and is normatensive,
administering the epinephrine and then applying the oxygen, watching
for hypotension and shock are later responses. The prevention of a
severe crisis is maintained by using diphenhydramine.
4. Which of these children at the site of a disaster at a child day care
center would the triage nurse put in the "treat last" category?
An infant with intermittent buldging anterior fontonel between crying
episodes
A toddler with severe deep abrasions over 98% of the body
A preschooler with 1 lower leg fracture and the other leg with an upper
leg fracture
A school-age child with singed eyebrows and hair on the arms
Review Information: The correct answer is B: A toddler with severe
deep abrasions over 98% of the body .This child has the least chance
of survival. Severe deep abrasions are to be thought of as second and
third degree burns. The child has great risk of shock and infection
combined.
5. When admitting a client to an acute care facility, an identification
bracelet is sent up with the admission form. In the event these do not
match, the nurse’s best action is to
change whichever item is incorrect to the correct information
use the bracelet and admission form until a replacement is supplied
notify the admissions office and wait to apply the bracelet
make a corrected identification bracelet for the client
Review Information: The correct answer is C: notify the admissions
office and wait to apply the bracelet
The Admissions Office has the responsibility to verify the client’s
identity and keep all the records in the system consistent. Making the
changes puts the client at risk for misidentification. Using an incorrect
identification bracelet is unsafe. Making a new bracelet on the unit is
not appropriate.
6. The nurse is having difficulty reading the health care provider's
written order that was written right before the shift change. What [Show Less]