Question

In: Nursing

1. a nurse is completing an assessment following suctioning of a child who has a tracheostomy....

1. a nurse is completing an assessment following suctioning of a child who has a tracheostomy. which of the following findings should the nurse identify as an indication that the procedure has been effective?

a. increased RR.

b. decreased O2 sat.

c. clear breath sounds.

d. increased oral secretions.

2. a nurse is developing a plan of care for a 4-year-old child who has hemophilia and is experiencing acute hemarthrosis. which of the following interventions should the nurse include in the plan?

a. have the child perform passive ROM exercises.

b. administer aspirin PRN for pain.

c. place ice packs on the affected joints.

d. position the lower extremities below the level of the heart.

3. a nurse is providing discharge teaching to the parents of a child who has sickle cell anemia and was hospitalized after experiencing a vasoocclusive crisis. which of the following instructions should the nurse include in the teaching?

a. avoid immunizing your child with the meningococcal vaccine.

b. restrict the time your child spends playing outdoors.

c. increase your child's intake of oral fluids.

d. provide your child with a high-protein diet.

4. a nurse is providing teaching to the parent of a school-age child who has pediculosis capitis. which of the following instructions should the nurse include in the teaching?

a. seal non washable items in a plastic bag for 2 days.

b. soak hair brushes in boiling water for 10 minutes.

c. apply permethrin 1% cream rinse everyday for 5 days.

d. after washing bed linens, place them in a dryer on a cool setting for 30 minutes.

Expert Solution

Q. 1

Clear breath sound will be your answer. Now let me explain why other are wrong and it is right ?

a) increase respiration rate :- Respiration rate will be increased by respiratory center when patient do not get appropriate amount of oxygen. So it is the sign of worsning not getting better, so it is wrong.

b) trachiostomy is done to improve oxygen saturation if there is decrease in oxygen saturation than it mean that the procedure is not effective. Oxygen saturation improvement is the goal of trachiostomy but in option is said that "decrease in saturation" so it is wrong.

d) increase oral secretion can further lead to the worsening the condition of the infant because it can lead to obstruction in respiratory tract. So is also wrong.

c) clear breath sound is showing that your respiratory function become start to work normally and it indicate that the procedure has been effective.

Q. 2

a) perform ROM exercise is also correct but when the child's condition is stable but here child is suffering from hemarthrosis(join cavity bleeding) so it will be your later intervention

b) Aspirin has the antiplatelet action so it can increase the chances of bleeding so aspirin is never given to the patient of hemophilia.

c) application of ice packs will helpful in diminishing swelling and pain. Ice application will reduce bleeding by local vasoconstriction. But must be use cautiously to prevent skin breakdown. So it will your correct answer.

d) lower extremities should be elevated above the level of heart instead of lowering it.Elevation of leg will promote to return of the blood to heart.

Q. 3

Menigococcal vaccine is recommended for the patient older than 2 year with sickle cell anemia.

Should not advice to restrict the child playing time.

Sickle cell crisis can be precipited by the fluid volume deficit or dehydration. So the nurse instruct the child parent to increase fluid intake.

Balance diet will be more helpful in sickle cell anemia.

Q. 4

a) items that can not be washed should place in sealed beg for 14 days to kill the lice not "2 days"

b) all items that can be washed such as clothing, towel, hair brushes that may have lice or nits should be washed in hot water (54 degree Celsius) not in "boiled water"

c) permethrin 1 percent can be apply to treat pediculosis capitis. So it will be correct answer.

d) after washing the bed linen should be hot dried for 20 minutes not in cool dried setting.

Nightingale answered 2 years ago

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