A nurse is contributing to the plan of care of a 14-month-old toddler who is 24 h following interventions should the nurse include in the plan?

Give the toddler a hard-tipped sippy cup to drink liquid

Suction the toddler nose and mouth every hour

Maintain elbow restraint

Provide soft foods for the toddler

Answer and Explanation

The Correct Answer is D

A. Give the toddler a hard-tipped sippy cup to drink liquid:

Giving a toddler a hard-tipped sippy cup with a hard spout can increase the risk of injury, especially if the toddler falls while using it. Toddlers at this age are still developing coordination and may not have the motor skills to handle a hard-tipped cup safely. Therefore, this choice would not be appropriate and could potentially harm the toddler.

B. Suction the toddler nose and mouth every hour:

Frequent suctioning of the nose and mouth every hour can cause irritation and discomfort to the toddler. While suctioning may be necessary in certain medical situations, such as clearing mucus or secretions, it should not be done routinely every hour without a specific medical indication. Overuse of suctioning can damage the delicate tissues in the nose and mouth and disrupt the normal mucous membranes.

C. Maintain elbow restraint:

Maintaining elbow restraint is not a standard intervention for a toddler who is 24 hours post-intervention unless there is a specific medical reason for it, such as preventing the toddler from accessing an IV site or medical device. Restraining a toddler's elbows without a clear medical indication can be distressing for the child and may impede their ability to move and explore their environment, which is important for their development.

D. Provide soft foods for the toddler:

Providing soft foods for the toddler is the most appropriate intervention in this scenario. Soft foods are easier for toddlers to chew and swallow, reducing the risk of choking or discomfort, especially if the toddler has undergone certain interventions that may affect their ability to eat solid foods comfortably. Soft foods can include mashed fruits and vegetables, cooked grains, pureed meats, and other easily digestible options suitable for a toddler's age and developmental stage.

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Correct Answer is B

Explanation

A. "When I use this technique the medication will not run out of the ear."

This explanation is not entirely accurate. While pulling the auricle down and back may help prevent ear drops from immediately dripping out of the ear, the primary purpose of this technique is to straighten the ear canal, facilitating the passage of the medication into the inner ear region for optimal effectiveness. The prevention of medication runoff is a secondary benefit.

B. “This opens the ear canal, allowing medication to reach the inner ear region.”

This explanation is correct. Pulling the auricle down and back helps to straighten the ear canal, making it easier for the ear drops to enter the ear canal and reach the inner ear where they can effectively treat the condition. This is the main purpose of using this technique.

C. “This is the safest and easiest way to administer this medication.”

While pulling the auricle down and back is a commonly used technique for administering ear drops, describing it as the safest and easiest way may not fully capture its purpose. Safety and ease of administration are important considerations, but the primary rationale for this technique is to facilitate the delivery of medication to the inner ear.

D. “When I use the technique, your child experiences less pain.”

This explanation is inaccurate. Pulling the auricle down and back may not directly reduce pain. The main purpose of this technique is to ensure that the medication reaches the inner ear region for effective treatment. While discomfort during administration may be minimized with proper technique, the primary focus is on medication delivery rather than pain reduction.

A. Decreased stridor B. Increased restlessness C. Decreased heart rate D. Decreased temperature

Correct Answer is B

Explanation

A. Decreased stridor: Stridor is a high-pitched, noisy breathing sound caused by turbulent airflow through a narrowed or partially obstructed airway. In laryngotracheobronchitis, stridor is often present and may worsen with increasing airway obstruction. Therefore, decreased stridor would not be a typical finding associated with airway obstruction in this condition.

B. Increased restlessness: Increased restlessness can be a sign of worsening respiratory distress and impending airway obstruction. As the child struggles to breathe, they may become increasingly agitated and restless, indicating the need for prompt intervention to ensure adequate oxygenation.

C. Decreased heart rate: Decreased heart rate (bradycardia) is not typically associated with airway obstruction in laryngotracheobronchitis. In fact, the heart rate may increase as a compensatory response to hypoxia and respiratory distress.

D. Decreased temperature: Changes in temperature are not typically associated with airway obstruction in laryngotracheobronchitis. The focus of monitoring in this condition is primarily on respiratory distress and signs of worsening airway obstruction.

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A nurse is contributing to the plan of care of a 14-month-old toddler who is 24 h following interventions should the nurse include in the plan?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

While administering ear drops to a toddler, a nurse by pulls the auricle down and back. The mother asks, "Why are you pulling the ear that way?" Which of the following responses should the nurse make?

Correct Answer is B

Explanation

A nurse is caring for a toddler who has laryngotracheobronchitis. For which of the following findings should the nurse monitor to detect airway obstruction?

Correct Answer is B

Explanation

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