A home health nurse is caring for a child who has Lyme disease. Which of the following is an appropriate action for the nurse to take?

Ensure the state health department has been notified.

Administer antitoxin.

Educate the family to avoid sharing personal belongings.

Assess for skin necrosis.

Answer and Explanation

The Correct Answer is A

The nurse should ensure the state health department has been notified of the child’s Lyme disease, as it is a reportable disease in most states. Reporting helps to monitor the incidence and prevalence of Lyme disease and to implement prevention and control measures.

Choice B is wrong because antitoxin is not used to treat Lyme disease.

Antitoxin is a substance that neutralizes the effects of a toxin, such as botulism or tetanus. Lyme disease is caused by a bacterium called Borrelia burgdorferi, which can be treated with antibiotics.

Choice C is wrong because Lyme disease is not transmitted by sharing personal belongings. Lyme disease is spread to humans by the bite of infected ticks that carry the bacterium. The risk of getting Lyme disease can be reduced by avoiding tick-infested areas, wearing protective clothing, using insect repellent, and removing ticks promptly.

Choice D is wrong because skin necrosis is not a common complication of Lyme disease.

Skin necrosis is the death of skin tissue due to lack of blood supply or infection. Lyme disease can cause a characteristic skin rash called erythema migrans, which is usually circular or oval and expands over time. Other possible signs and symptoms of Lyme disease include fever, headache, fatigue, joint pain, and neurological problems.

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Correct Answer is C

Explanation

The correct answer is **c. Applies suction for 15 seconds**.

**Choice A rationale:** Inserting the catheter without applying suction is a proper step in the suctioning process. This action does not require intervention by the staff nurse.

**Choice B rationale:** Waiting for 2 minutes between suctions is a standard practice to prevent damage to the trachea and to allow the client to recover from the suctioning process. This action is also appropriate and does not require intervention.

**Choice C rationale:** Applying suction for 15 seconds is too long and can cause damage to the trachea. The recommended duration for suctioning is typically 5-10 seconds. This action requires intervention by the staff nurse to correct the procedure and ensure the client's safety.

**Choice D rationale:** Encouraging the client to cough during suctioning is a proper step to help clear the trachea and promote effective suctioning. This action does not require intervention by the staff nurse.

In summary, the newly licensed nurse's action of applying suction for 15 seconds is the one that requires intervention by the staff nurse to correct the procedure and ensure the client's safety.

A. Elevated pain level. B. Increased drowsiness. C. Frequent swallowing. D. Diminished breath sounds.

Correct Answer is C

Explanation

This indicates that the child may be experiencing hemorrhage because they are trying to clear the blood from their throat. Frequent swallowing is one of the initial signs of bleeding immediately after tonsillectomy.
Choice A is wrong because elevated pain level is not a specific sign of hemorrhage. Pain is expected after a tonsillectomy and can be managed with medication and fluids.
Choice B is wrong because increased drowsiness is not a specific sign of hemorrhage. Drowsiness can be caused by anesthesia, medication, or dehydration.

Choice D is wrong because diminished breath sounds are not a specific sign of hemorrhage. Diminished breath sounds can be caused by respiratory infection, asthma, or bronchospasm.
Normal ranges for hemoglobin and hematocrit are 11.5 to 15.5 g/dL and 34 to 45% for children, respectively.
Normal ranges for platelet count are 150,000 to 450,000/mm3 for both children and adults. Normal ranges for plasma clotting variables depend on the specific test and method used.

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A home health nurse is caring for a child who has Lyme disease. Which of the following is an appropriate action for the nurse to take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A staff nurse is observing a newly licensed nurse suction a client’s tracheostomy. Which of the following actions by the newly licensed nurse requires intervention by the staff nurse?

Correct Answer is C

Explanation

A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following findings indicates that the child may be experiencing hemorrhage?

Correct Answer is C

Explanation

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