Chapter 22: Health Care Adaptations for the Child and Family
MULTIPLE CHOICE
1. What is the best pulse location for the nurse to use when assessing the
... [Show More] pulse rate on a 12-month-old infant?
a. Brachial
b. Apical
c. Radial
d. Femoral
ANS: B
Apical pulses are advised for children under age 5 years. DIF: Cognitive Level: Knowledge REF: Page 502
TOP: Physical Assessment KEY: Nursing Process Step: Data Collection
MSC: NCLEX: Physiological Integrity: Physiological Adaptation
2. The nurse preparing to administer medication to a 2-month-old infant discovers there is no ID bracelet on
the child. What should be the next action by the nurse?
a. Give the medication after confirming the childs name from the foot of the crib. b. Ask the charge nurse to give the medicine. c. Confirm the identity with the charge nurse, make a new bracelet, and give the medicine. d. Delay the medication until the admissions office can supply a new ID bracelet.
ANS: C
After confirmation of the childs identity with the charge nurse and making a new bracelet, the medication can
be safely given. All patients should be identified before treatment. DIF: Cognitive Level: Application REF: Page 497
OBJ: 2 TOP: ID Bracelets KEY: Nursing Process Step: Implementation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
3. The nurse instructed an adolescent female about collecting a clean-catch urine specimen. What statement
made by the adolescent led the nurse to determine she understood the instructions?
a. I should wash my perineum with soap and water, then begin to urinate. b. I clean the perineum from front to back with an antiseptic wipe before I urinate. c. Ill collect the first stream of urine in a sterile container. d. I will discard the first void and collect a freshly voided specimen 30 minutes later.
ANS: B
To obtain a clean-catch specimen, the perineum is cleansed with an antiseptic wipe from front to back. DIF: Cognitive Level: Analysis REF: Page 508
TOP: Collecting Specimens KEY: Nursing Process Step: Evaluation
MSC: NCLEX: Safe, Effective Care Environment: Safety and Infection Control
4. Which strategy might the nurse use when administering oral medications to a young child who is reluctant? [Show Less]