🔷 The client should use the PCA button before activities such as turning, coughing, deep breathing, ambulation, or physical therapy.

🔷 This helps maintain therapeutic pain control and improves the client’s ability to participate in recovery activities.

🔷 PCA devices are programmed with a lockout interval, so the client cannot receive unsafe extra doses by repeatedly pressing the button.

🔷 Only the client should press the PCA button because the dose should be based on the client’s own pain perception.

🔷 Preemptive pain control helps prevent severe pain, which is harder to manage once it becomes intense.

The PCA will deliver a double dose of medication when you push the button twice.

🔷 PCA pumps have a lockout safety feature that prevents double dosing.

🔷 Pressing the button repeatedly will not deliver extra medication during the lockout period.

You can adjust the amount of pain medication you receive by pushing on the keypad.

🔷 The medication dose is programmed by the provider and nurse, not adjusted by the client.

🔷 The client can only activate the preset dose using the button.

Continuous PCA infusion is designed to allow fluctuating plasma medication levels.

🔷 PCA is designed to maintain more stable pain control, not fluctuating medication levels.

🔷 Continuous basal infusions may be used for some clients but require close monitoring for respiratory depression.

💎 Giving water after digoxin helps ensure the toddler swallows the full dose.

💎 It also helps clear the medication from the mouth and reduces unpleasant taste.

💎 Digoxin should be given exactly as prescribed using a calibrated oral syringe.

💎 Parents should check the child’s pulse as instructed before giving the medication.

💎 Signs of digoxin toxicity include vomiting, poor feeding, bradycardia, fatigue, and rhythm changes.

Repeat the dose if your child vomits within 1 hour after taking the medication.

💎 The dose should not be repeated after vomiting because this can cause toxicity.

💎 The parent should notify the provider for further instructions.

Limit your child's potassium intake while they are taking this medication.

💎 Low potassium increases the risk of digoxin toxicity.

💎 Potassium intake should not be restricted unless specifically prescribed.

You can add the medication to a half-cup of your child's favorite juice.

💎 Digoxin should not be mixed with a large amount of food or liquid.

💎 If the child does not finish the juice, the full dose may not be received.

🟢 Establishing an elimination schedule reduces the client’s need to get up urgently or without assistance.

🟢 Toileting needs are a common cause of falls, especially in older adults or confused clients.

🟢 Scheduled toileting promotes safety while also preserving dignity and comfort.

🟢 This intervention helps prevent impulsive attempts to walk to the bathroom alone.

🟢 Fall prevention should include frequent rounding, call light access, bed alarms when needed, and clutter-free pathways.

Raise all four bed rails on the client's bed.

🟢 Raising all four side rails can be considered a restraint.

🟢 It may also increase injury risk if the client tries to climb over them.

Silence the bed alarm when visitors are at the client's bedside.

🟢 Bed alarms should remain active if the client is at risk for falls.

🟢 Visitors may not recognize unsafe movement quickly enough to prevent injury.

Allow the client to walk unassisted near the nursing station.

🟢 A client on fall precautions should not ambulate without needed assistance.

🟢 Being near the nursing station does not remove the risk of falling.

🟣 A history of gastroesophageal reflux disease increases the risk for aspiration during enteral feedings.

🟣 Reflux allows gastric contents to move back into the esophagus and potentially enter the airway.

🟣 Clients receiving tube feedings are at higher risk when gastric emptying is delayed or reflux is present.

🟣 The nurse should keep the head of the bed elevated during and after feeding as prescribed.

🟣 Monitoring tolerance, respiratory status, and signs of regurgitation helps reduce aspiration risk.

Receiving a high-osmolarity formula.

🟣 High-osmolarity formulas are more associated with diarrhea, cramping, and delayed tolerance.

🟣 They are not the strongest aspiration risk listed here.

Sitting in high-Fowler's position during the feeding.

🟣 High-Fowler’s position helps reduce aspiration risk.

🟣 It promotes gastric emptying and prevents reflux into the airway.

A residual of 65 mL 1-hr postprandial.

🟣 A residual of 65 mL is generally not a major aspiration indicator by itself.

🟣 Residual interpretation depends on facility policy, feeding type, and the client’s overall condition.

🟡 A 4-month-old with gastroesophageal reflux who is experiencing weight loss needs revision of the care plan.

🟡 Weight loss suggests inadequate nutrition, poor feeding tolerance, or worsening reflux complications.

🟡 Infants with reflux should be monitored closely for growth, hydration, feeding difficulty, and respiratory symptoms.

🟡 The plan may need changes such as feeding modifications, positioning guidance, medication review, or provider reevaluation.

🟡 In pediatric clients, failure to gain weight or weight loss is a concerning finding that requires prompt intervention.

A 6-year-old child who underwent a Nissen fundoplication and is tolerating a full liquid diet.

🟡 Tolerating a full liquid diet after fundoplication can be appropriate during diet advancement.

🟡 The child should continue gradual progression as prescribed.

A 14-year-old child who eats small but frequent meals throughout the day.

🟡 Small frequent meals are appropriate for managing reflux symptoms.

🟡 This reduces gastric distention and lowers reflux episodes.

A 16-year-old child who takes their proton pump inhibitor 30 min before meals.

🟡 Taking a proton pump inhibitor before meals supports best medication effect.

🟡 PPIs work best when taken before food stimulates acid production.

🔴 Absence seizures often appear as brief episodes of staring or blanking out.

🔴 The child may suddenly stop activity and then resume as if nothing happened.

🔴 These seizures are commonly mistaken for daydreaming, inattention, or not listening.

🔴 They usually last only a few seconds and may occur many times per day.

🔴 The child typically has no memory of the event and no prolonged postictal confusion.

This type of seizure lasts 30 to 60 seconds.

🔴 Absence seizures usually last less than 10 to 20 seconds.

🔴 Longer events may suggest another seizure type.

This type of seizure has a gradual onset.

🔴 Absence seizures have a sudden onset and sudden ending.

🔴 The child usually returns quickly to baseline activity.

The child usually has an aura prior to onset.

🔴 Absence seizures typically occur without an aura.

🔴 Auras are more commonly associated with focal seizures.

✅ Unexplained bruises can indicate possible child abuse or neglect.

✅ The school nurse is a mandatory reporter and must report suspected abuse according to law and policy.

✅ The nurse does not need proof of abuse before reporting; reasonable suspicion is enough.

✅ Prompt reporting protects the child and allows trained agencies to investigate safely.

✅ Documentation should include objective descriptions such as bruise location, size, color, and the child’s statements.

Arrange for a meeting with the child's guardians tomorrow.

✅ Meeting the guardians first can delay protection and may place the child at further risk.

✅ Suspected abuse should be reported promptly to the proper authority.

Notify the president of the school board.

✅ The school board president is not the appropriate reporting authority.

✅ Child protective services is responsible for investigating suspected abuse.

Ask the child's peers about the bruises.

✅ Asking peers violates privacy and may spread sensitive information.

✅ The nurse should use objective assessment and mandated reporting procedures.

⚪ The client’s advance directives should guide care when the client cannot speak for themselves.

⚪ Advance directives communicate the client’s wishes about life-sustaining treatment.

⚪ When the family disagrees, an ethics committee consultation can help clarify legal, ethical, and clinical responsibilities.

⚪ The nurse should advocate for the client’s expressed wishes while supporting the family emotionally.

⚪ Ethics consultation helps resolve conflict without ignoring the client’s autonomy.

Support the family’s decision and initiate life-sustaining measures.

⚪ The family cannot override valid advance directives simply because they disagree.

⚪ Initiating unwanted life-sustaining measures violates the client’s autonomy.

Encourage the family to contact an attorney.

⚪ Legal advice may be pursued by the family, but it is not the nurse’s priority action.

⚪ The immediate nursing action is to use the facility’s ethics process.

Complete an incident report.

⚪ An incident report is used for unusual events, errors, or safety occurrences.

⚪ A disagreement about advance directives is better addressed through ethics consultation.

🟠 Displacement occurs when a person redirects feelings from the true source to a safer or less threatening target.

🟠 A client experiencing chronic stress might feel anger from work, illness, or conflict but express it toward family members.

🟠 The family members are not the actual cause of the stress, but they become the outlet for the emotion.

🟠 This defense mechanism is often unconscious and can strain relationships.

🟠 Recognizing displacement helps the nurse support healthier coping and emotional expression.

The client states, “I only act this way because my partner makes me angry.”

🟠 This reflects projection or blaming, not displacement.

🟠 The client is attributing responsibility for their behavior to another person.

The client refuses to accept treatment for their diagnosis.

🟠 Refusing to accept a diagnosis or treatment is more consistent with denial.

🟠 Denial involves avoiding reality because it is emotionally difficult to face.

The client brings a list of questions about their diagnosis to their appointment.

🟠 This shows active coping and information seeking.

🟠 It is not a maladaptive defense mechanism.

Assist students in developing a recipe book of healthy foods

🟤 Involving students in creating a recipe book promotes active learning and ownership of healthy choices.

🟤 Children are more likely to try healthy foods when they participate in planning and preparation ideas.

🟤 This intervention also supports family involvement if recipes are shared at home.

Have teachers and school personnel model healthy eating behaviors

🟤 School-age children learn strongly through role modeling.

🟤 When teachers and staff choose healthy foods, students are more likely to view those choices as normal and desirable.

🟤 Consistent modeling reinforces nutrition education beyond the classroom.

Provide fruits and vegetables as snacks at school sporting events

🟤 Offering fruits and vegetables increases access to nutrient-dense snacks.

🟤 Sporting events are good opportunities to normalize healthy snacks in social settings.

🟤 This supports better long-term eating habits and reduces reliance on high-sugar snacks.

Recommend removing complex carbohydrate snacks from school vending machines.

🟤 Complex carbohydrates are part of a healthy diet when they come from whole grains, fruits, vegetables, and legumes.

🟤 The focus should be reducing low-nutrient, high-sugar, and high-fat snacks rather than removing healthy carbohydrates.

Offer a dessert to students who finish their lunch.

🟤 Using dessert as a reward can teach children to value sweets more than healthy foods.

🟤 It may also encourage overeating or unhealthy food relationships.