Question

A nurse is caring for a child who is brought to the urgent care clinic following exposure to poison ivy 1 hr ago. Which of the following actions should the nurse take first?

Answer 1

Correct Answers:

Flush the area with cold, running water.

Rationale :

🔷 Decontamination with water removes urushiol from poison ivy.

🔷 Reduces severity by stopping absorption of the allergen.

🔷 Immediate action limits spread and severity.

🔷 Symptom treatments (lotions, steroids) come after cleansing.

🔷 Early flushing is most effective for prevention.

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Answer 2

Correct Answers:

Apply suction in 3 to 4-second increments.

Rationale :

🟢 Short suction times reduce risk of hypoxia and trauma.

🟢 Protects delicate airway in infants.

🟢 Avoids prolonged negative pressure.

🟢 Other steps (catheter size, technique) are important, but suction duration is key.

🟢 Safe practice ensures effective mucus removal.

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Answer 3

Correct Answers:

Reposition the probe every 2 hr.

Rationale :

💠 Prevents skin breakdown from continuous pulse oximetry.

💠 Maintains accurate readings by avoiding local perfusion issues.

💠 Routine changes promote comfort and safety.

💠 Avoid taping wires or prolonged use on one site.

💠 Site rotation is standard care.

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Answer 4

Correct Answers:

Diminished pulses.

Rationale :

🔴 Decreased cardiac output leads to weak or diminished pulses.

🔴 Reflects poor perfusion after cardiac surgery.

🔴 Early sign of complications.

🔴 Monitor for other perfusion changes.

🔴 Requires prompt assessment and intervention.

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Answer 5

Correct Answers:

WBC 17,500/mm3.

Rationale :

🟡 Elevated WBC indicates infection or inflammation.

🟡 Normal value is much lower in children.

🟡 Needs rapid reporting for prompt treatment.

🟡 Not explained by dehydration, BUN, or urine results.

🟡 Early reporting aids infection control.

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Answer 6

Correct Answers:

Place a urine collection device on the infant until the specimen is obtained.

Rationale :

🔷 Collection devices help obtain a pure stool sample for ova and parasite testing, preventing urine contamination.

🔷 Using a urine bag keeps the area clean and separates urine from stool, which is critical for accurate lab analysis.

🔷 Rectal swabs may not provide enough material and can miss parasite eggs present in stool.

🔷 Maintaining the sample in a controlled environment (not room temperature) preserves organism viability for reliable results.

🔷 Proper specimen collection is crucial for diagnosis and guiding correct treatment.

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Answer 7

Correct Answers:

Maintain bed rest to prevent hypoxemia.

Rationale :

🟢 Bed rest minimizes the body's oxygen needs, crucial during sickle cell vaso-occlusive crisis to prevent further sickling of red blood cells.

🟢 Limiting activity reduces the risk of worsening hypoxemia, as physical exertion can precipitate additional sickling episodes.

🟢 Promoting rest allows for better pain control and supports tissue perfusion.

🟢 Cold compresses are avoided as cold can trigger more sickling by causing vasoconstriction.

🟢 Ensuring adequate hydration and rest are standard non-pharmacological approaches in crisis management.

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Answer 8

Correct Answers:

Apply protective padding to the end of the pin sites.

Rationale :

💠 Protective padding shields the skin from friction and pressure caused by the ends of skeletal traction pins, reducing the chance of breakdown and infection.

💠 Padded pin sites prevent accidental trauma to skin and soft tissue during movement.

💠 Padding is a key part of maintaining pin site integrity and helps avoid secondary complications like cellulitis or osteomyelitis.

💠 Skin integrity checks should be routine to detect early issues.

💠 Other interventions (ROM exercises, lifting weights) do not address this specific risk.

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Answer 9

Correct Answers:

A 4-year-old child who has a history of frequent urinary tract infections.

Rationale :

🔴 Frequent UTIs in a young child are a red flag for possible abuse or neglect and require provider investigation.

🔴 Chronic infections can indicate poor hygiene, structural problems, or maltreatment, especially in non-toilet trained children.

🔴 Reporting is a legal and ethical obligation for healthcare providers to protect vulnerable children.

🔴 Injuries common to active play or isolated biting incidents are not as concerning for maltreatment.

🔴 Early identification can lead to timely intervention, preventing further harm.

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Answer 10

Correct Answers:

Elevate the extremity above the level of the heart.

Rationale :

🟡 Elevation helps control swelling after a sprain by facilitating return of excess fluid from the injury site back into circulation.

🟡 Keeping the injured part above the heart reduces hydrostatic pressure, lessening edema formation.

🟡 Early elevation in the first 12–24 hours is most effective in limiting the inflammatory response.

🟡 Other measures (ice, compression) may be helpful, but elevation is critical for minimizing pain and speeding recovery.

🟡 Avoid heat or movement at this stage, as they may worsen swelling and delay healing.

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QLexNursing

1 :
A nurse is caring for a child who is brought to the urgent care clinic following exposure to poison ivy 1 hr ago. Which of the following actions should the nurse take first?

2 :
A nurse is preparing to perform suctioning for an infant who has a partial mucus occlusion of her tracheostomy tube. Which of the following actions should the nurse plan to take?

3 :
A nurse is caring for a school-age child who has a new prescription for continuous pulse oximetry monitoring. Which of the following actions should the nurse take?

4 :
A nurse is assisting with the care of a preschooler who is postoperative following tetralogy of Fallot correction. Which of the following manifestations indicates the child is possibly experiencing decreased cardiac output?

5 :
A nurse is reviewing the laboratory report of a newly admitted school-age child who has a fever. The nurse should identify which of the following laboratory results is an indication of an infection and should be reported to the charge nurse immediately.

6 :
A nurse is planning to collect a stool specimen from an infant to check for the presence of ova and parasites. Which of the following actions should the nurse plan to take?

7 :
A nurse is contributing to the plan of care for an adolescent client who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions should the nurse include in the plan?

8 :
A nurse is assisting with the care of an adolescent client who is in skeletal traction for the treatment of a fractured femur. Which of the following actions should the nurse take?

9 :
A nurse in a well-child clinic is collecting data from four clients. Which of the following findings should the nurse report to the provider as a potential indication of child maltreatment?

10 :
A nurse is reinforcing teaching with a parent of a child who has a sprained wrist. Which of the following interventions should the nurse instruct the parent to implement during the first 12 to 24 hours to minimize swelling?

QLexNursing

1 : A nurse is caring for a child who is brought to the urgent care clinic following exposure to poison ivy 1 hr ago. Which of the following actions should the nurse take first?

2 : A nurse is preparing to perform suctioning for an infant who has a partial mucus occlusion of her tracheostomy tube. Which of the following actions should the nurse plan to take?

3 : A nurse is caring for a school-age child who has a new prescription for continuous pulse oximetry monitoring. Which of the following actions should the nurse take?

4 : A nurse is assisting with the care of a preschooler who is postoperative following tetralogy of Fallot correction. Which of the following manifestations indicates the child is possibly experiencing decreased cardiac output?

5 : A nurse is reviewing the laboratory report of a newly admitted school-age child who has a fever. The nurse should identify which of the following laboratory results is an indication of an infection and should be reported to the charge nurse immediately.

6 : A nurse is planning to collect a stool specimen from an infant to check for the presence of ova and parasites. Which of the following actions should the nurse plan to take?

7 : A nurse is contributing to the plan of care for an adolescent client who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions should the nurse include in the plan?

8 : A nurse is assisting with the care of an adolescent client who is in skeletal traction for the treatment of a fractured femur. Which of the following actions should the nurse take?

9 : A nurse in a well-child clinic is collecting data from four clients. Which of the following findings should the nurse report to the provider as a potential indication of child maltreatment?

10 : A nurse is reinforcing teaching with a parent of a child who has a sprained wrist. Which of the following interventions should the nurse instruct the parent to implement during the first 12 to 24 hours to minimize swelling?

1 :
A nurse is caring for a child who is brought to the urgent care clinic following exposure to poison ivy 1 hr ago. Which of the following actions should the nurse take first?

2 :
A nurse is preparing to perform suctioning for an infant who has a partial mucus occlusion of her tracheostomy tube. Which of the following actions should the nurse plan to take?

3 :
A nurse is caring for a school-age child who has a new prescription for continuous pulse oximetry monitoring. Which of the following actions should the nurse take?

4 :
A nurse is assisting with the care of a preschooler who is postoperative following tetralogy of Fallot correction. Which of the following manifestations indicates the child is possibly experiencing decreased cardiac output?

5 :
A nurse is reviewing the laboratory report of a newly admitted school-age child who has a fever. The nurse should identify which of the following laboratory results is an indication of an infection and should be reported to the charge nurse immediately.

6 :
A nurse is planning to collect a stool specimen from an infant to check for the presence of ova and parasites. Which of the following actions should the nurse plan to take?

7 :
A nurse is contributing to the plan of care for an adolescent client who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions should the nurse include in the plan?

8 :
A nurse is assisting with the care of an adolescent client who is in skeletal traction for the treatment of a fractured femur. Which of the following actions should the nurse take?

9 :
A nurse in a well-child clinic is collecting data from four clients. Which of the following findings should the nurse report to the provider as a potential indication of child maltreatment?

10 :
A nurse is reinforcing teaching with a parent of a child who has a sprained wrist. Which of the following interventions should the nurse instruct the parent to implement during the first 12 to 24 hours to minimize swelling?