Question

13a. Mary is transferred from the emergency department to the pediatric intensive care department. In developing the plan of care, the nurse identifies the nursing diagnosis, “Acute pain related to tissue ischemia” as a priority.

13b. Which intervention should be included in the care plan?

1. Explain how to use a patient controlled analgesic pump.

2. Apply cold compresses periodically to painful joints.

3. Administer acetaminophen PRN for pain.

4. Assess pain by using a numerical pain scale

14. The night nurse assesses Mary and notes that her vital signs are now T 98.3, P 108, R 22, BP 96/60. Which action should the nurse implement?

1. Encourage Mary to turn, cough, and deep breathe

2. Notify the healthcare provider immediately

3. Document the findings on the graphic sheet.

4. Retake and assess the vital signs in 1 hour

15a. The ICU night nurse is making rounds and hears Mary crying. The nurse says, “Mary, are you hurting?” Mary cries harder and replies, “No, I just miss my Mommy.” Mary’s grandmother has gone home to rest for a few hours.

15b. How should the nurse intervene initially

1. Pull up a chair, hold Mary's hand, and allow her to cry

2. Tell Mary she needs to try and quit crying and get some sleep.

3. Call Mary’s grandmother and ask her to come to the hospital.

4. Say, “I know how hard it is to lose your Mommy. Mine is gone too.”

16. Mary is in the ICU for 3 days and is transferred to the pediatric floor. Earlene has been at the hospital every day and is very concerns about Mar and he condition. Earlene asks the nurse, “What can I do to make sure this never happens again?” What is the best initial response by the nurse?

1. “When Mary gets a fever give her 1 baby aspirin.”

2. “Make sure she does not participate in any strenuous activity.”

3. There is no way you can make sure this never happens again.”

4.“Keep Mary away from anyone who has an infection.”

17. Mary’s grandmother goes downstairs to get something to eat form the hospital cafeteria. The UAP who is staying with Mary while her grandmother is gone informs the primary nurse that Mary urinated in the bed, is crying, and wants her grandmother. Which intervention should the nurse implement first?

1. Find Earlene in the cafeteria

2. Change Mary’s bed linens.

3. Help Mary change her clothes

4. Document the incident in Mary’s chart

18a. Mary is starting to feel better and is requiring less pain medication, and she is sleeping as the nurse makes evening rounds. Earlene shares with the nurse it has been a long time since she has had a 7-year-old-in her home. Earlene says, “I have no idea what Mary should be allowed to do so she can have some fun.”

18b. Which statement will be the best response by the nurse?

1. “Mary should not be around a lot of children, so her activities will be limited

2. “You should like you are worried about raising Mary by yourself,”

3. “I would recommend enrolling her in a sport with running, such as soccer.

4. Seven-year-olds really like being in groups like Girl Scouts or Girl's Clubs.

19. Which statement by Mary indicates that she is meeting Erickson's stage of development for her age?

1. “When I grow up I want to be a nurse just like you.”

2. “Look, I finished putting the puzzle together.”

3. “I need my stuffed dog so that I can go to sleep.”

4. “I don’t want any of my friends to visit me here.”

20a. Mary is scheduled for discharge the next day. The nurse is completing discharging teaching with Earlene when Earlene tells the nurse that she is planning to take Mary to Colorado to visit her oldest daughter and their family for the Christmas holidays. Mary is very excited and can’t wait to meet her cousin.

20b. What is the best response by the nurse?

1. “Your planned trip may put Mary at risk for a crisis.”

2. “I think you should talk to Mary’s healthcare provider before you go.”

3. “Could your daughter come here for the Christmas holidays?”

4. “I know that Mary will enjoy meeting her family.”

21a. Earlene asks many questions about SCA. She is very concerned about her granddaughter and what will happen to her the future. The nurse is aware that there are many serious complications that Mary could experience.

21b. Which potentially fatal complication(s) can occur? (Select all that apply.)

1. Hypertensive crisis

2. Vasoocclusive crisis.

3. Priapism

4. Heart failure

22. Mary’s HCP has advised Earlene to get pneumococcal and meningococcal vaccines for Mary at her follow-up office visit. Earlene asks the nurse, “Why does Mary need to have those other vaccines? I hate for her to get more shots. She cries, and I know it hurts.” What is the best response by the nurse?

1. “She is susceptible to infections. These vaccinations may help prevent a crisis.”

2. “I will get the healthcare provider to explain why Mary needs the vaccines.”

3. “I know you don’t like to see her hurt, but she must have these vaccines.”

4. “These vaccines are required for all children younger than 10 years of age.”

23a. The charge nurse is transcribing prescription at the nurse’s station. Other responsibilities of the charge nurse include answering the phone assisting with visitor’s questions and answering the clients’ call lights.

23b.  Which nursing task would be best for the charge nurse to delegate to the UAP?

1. Take the hourly vital signs for a client receiving a unit of blood.

2. Teach Mary’s grandmother how to apply warm soaks to her joins.

3. Change the morphine vial on the patient controlled analgesia pump.

4. Clean the insertion sites of a client with skeletal traction.

24a. Mary is discharged home with a home health referral. The home health nurse visiting Mary the day after she is discharged from the hospital. Earlene ask the home health nurse, “I received some information form the Sickle Cell Foundation, but I have never heard of it. What kind of group is it?”

24b. How should the nurse respond?

1. “It is a foundation that deals primarily with research to find the cure for sickle cell anemia.”

2. “They didn’t discuss this organization with you when Mary was in the hospital?”

3. “The foundation arranges for families with children who have sickle cell to meet each other.”

4. “It provides information on the disease and on support groups in this area.”

25. To evaluate the discharge teaching completed at the hospital, the home health nurse discusses acute exacerbation of SCA with Mary’s grandmother. Which behavior indicates to the nurse that Earlene understands about acute exacerbation of sickle cell anemia?

1. She does not allow Mary to go outside unless she is with her.

2. She measures Mary’s fluid intake to remain under 1 liter a day.

3. She demonstrates how to accurately read an oral thermometer.

4. She is able to take Mary’s radial pulse within 4 beats of the nurse.

Answer 1

13b) Administer Acetaminophen PRN for pain.

Apply cold compress periodically to joints

14) option 2_ Notify health care provider immediately.

15 b)

option 4 -Tell how hard is to loose your mommy, mine is gone too..

16) Option 4 -keep mary away from anyone whi has infection

17) option 3- help mary change her clothes.

18 b) option 4- seven year old really like being in goups like girls scout or girls club.

19) option 2- look i finished the puzzle together.

20) option2- i think you should talk to mary' s health care provider before you go.

21 b) option1- hypertensive crisis

22) option 3- i know you dont like to see her hurt, but she must have these vaccines.

23 b) option 2 - teach mary's grandmother how to apply warm socks to the joint.

24b) option 1- it is a foundation that primarly deals with reserch to find cure to sickle cell anemia.

25) option 3- she demonstrates how to accurately read oral thermometer.