A nurse is caring for a preschooler who is in an acute care facility. Which of the following actions should the nurse take?

Establish a new routine for the child to follow while in the facility.

Encourage the child to play with toys such as a pounding board.

Use medical terminology when discussing procedures with the child.

Perform the morning assessments when the parent is not in the room.

Answer and Explanation

The Correct Answer is B

A. Establish a new routine for the child to follow while in the facility. - Preschoolers thrive on routines and familiarity, especially in unfamiliar environments like acute care facilities. Therefore, it's essential for the nurse to maintain the child's existing routine as much as possible to provide a sense of security and stability.
B. Encourage the child to play with toys such as a pounding board. - Encouraging play with age-appropriate toys helps promote normalcy, reduce anxiety, and facilitate coping for preschoolers during their hospital stay. Toys like a pounding board provide opportunities for physical activity and engagement, which can help distract and entertain the child.
C. Use medical terminology when discussing procedures with the child. - Preschoolers have limited understanding of complex medical terminology. Using simple, age-appropriate language helps the child better comprehend what is happening, reducing fear and anxiety. Therefore, it's important for the nurse to avoid medical jargon and use language the child can understand.
D. Perform the morning assessments when the parent is not in the room. - Preschoolers often feel more comfortable and secure when their parents are present, especially in unfamiliar environments like hospitals. Performing assessments in the presence of the parent helps maintain the child's sense of security and allows the parent to participate in the child's care and provide comfort and support.

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Correct Answer is B

Explanation

A. "I will position the shoulder harness straps 3 inches above my baby's shoulders.": The shoulder harness straps should be positioned at or below the baby's shoulders, not above them, to ensure proper restraint in the event of a crash. Placing the straps too high can increase the risk of injury to the baby.
B. "I will position my baby at a 45-degree angle in the car seat.": This statement indicates an understanding of proper car seat positioning for a newborn. Newborns should be positioned at a 45-degree angle in a rear-facing car seat to keep the airway open and prevent head flopping, which can restrict breathing. This angle helps to keep the baby's head from falling forward and blocking the airway.
C. "I will turn the car seat forward-facing when my baby is 1 year old.": It is recommended to keep infants in a rear-facing car seat until they reach the maximum weight or height limit specified by the car seat manufacturer, typically around 2 years of age. Turning the car seat forward-facing prematurely increases the risk of injury to the baby's head, neck, and spine in the event of a crash.
D. "I will place the retainer clip on my baby's upper abdomen.": The retainer clip, also known as the chest clip, should be positioned at armpit level to properly secure the harness straps over the baby's shoulders. Placing the clip on the baby's upper abdomen can result in improper restraint and increase the risk of injury in a crash.

A. Acute hemolytic B. Allergic C. Bacterial D. Febrile nonhemolytic

Correct Answer is A

Explanation

A. Acute hemolytic:
Acute hemolytic transfusion reactions typically present with symptoms such as fever, chills, flank pain, hemoglobinuria (blood in the urine), and possibly hypotension. This occurs due to the rapid destruction of transfused red blood cells, often because of ABO incompatibility between the donor and recipient. The symptoms described in the scenario, including chest tightness, are not consistent with acute hemolytic reactions.

B. Allergic:
Allergic reactions to blood transfusions can manifest with symptoms such as itching, hives, flushing, and mild respiratory distress. While headache and low-back pain can occur in allergic reactions, the feeling of "tightness" in the chest is more indicative of another type of reaction.

C. Bacterial:
Bacterial contamination of blood products can lead to transfusion-related sepsis. Symptoms may include fever, chills, hypotension, and rapid onset of shock. However, the presence of headache and low-back pain, along with chest tightness, is not typically associated with bacterial contamination.

D. Febrile nonhemolytic:
Febrile nonhemolytic transfusion reactions are characterized by fever, chills, and rigors. While fever and chills are common symptoms, they do not typically cause chest tightness or low-back pain.

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A nurse is caring for a preschooler who is in an acute care facility. Which of the following actions should the nurse take?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

A nurse is teaching the guardian of a newborn about car seat safety. Which of the following statements by the guardian indicates an understanding of the teaching?

Correct Answer is B

Explanation

A nurse is monitoring a client who is receiving a transfusion of packed RBCs. The client reports chills, headache, low-back pain, and a feeling of "tightness" in their chest. The nurse should identify that the client has developed which of the following types of transfusion reactions?

Correct Answer is A

Explanation

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