A nurse is teaching the parents of a toddler about booster seat safety. Which of the following instructions should the nurse include?

Place the booster seat where there is an air bag in the vehicle.

Avoid using the lap shoulder belt when the child is in a booster seat.

Use a no-back booster seat if the vehicle seat has a headrest.

Keep the booster seat rear-facing until the child weighs at least 16 kg (35.3 lb

Answer and Explanation

The Correct Answer is C

A. Place the booster seat where there is an air bag in the vehicle. Booster seats should never be placed in front of an active air bag, especially in the front seat. Air bags can cause serious injury or death to young children in the event of deployment.
B. Avoid using the lap shoulder belt when the child is in a booster seat. A lap-shoulder belt is required for proper use of a booster seat. The shoulder belt helps distribute force across the child’s chest and shoulders in a crash. Using only a lap belt increases the risk of serious abdominal and spinal injuries.
C. Use a no-back booster seat if the vehicle seat has a headrest. This is correct and safe. A no-back booster is appropriate as long as the vehicle seat has a high back or headrest that provides support for the child’s neck and head, ensuring proper positioning of the seat belt.
D. Keep the booster seat rear-facing until the child weighs at least 16 kg (35.3 lb). Booster seats are designed for forward-facing children who have outgrown a forward-facing harness seat, typically around 4 years of age and 40 pounds. Rear-facing seats are used prior to booster seats, for infants and toddlers, not for booster seat-age children.

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Correct Answer is C

Explanation

A. Widening pulse pressure. This is typically associated with conditions like increased intracranial pressure or severe aortic regurgitation, not cardiac tamponade. Tamponade usually results in narrowed pulse pressure.
B. Coarse lung sounds. These may indicate fluid overload or pulmonary congestion, but they are not specific to cardiac tamponade and occur later or in different conditions.
C. Muffled heart sounds. This is a classic early sign of cardiac tamponade, caused by fluid accumulation in the pericardial sac, which dampens heart sounds on auscultation. It is part of Beck’s triad (muffled heart sounds, hypotension, and jugular vein distention).
D. Decreased jugular vein distention. In cardiac tamponade, jugular vein distention increases due to impaired venous return to the heart. Decreased JVD would be an unexpected finding in this condition.

A. Assess the client's peripheral pulses every 15 min. B. Change the client's dressing 4 hr following the procedure. C. Instruct the client to flex the right knee every 30 min. D. Elevate the head of the client's bed to 45"

Correct Answer is A

Explanation

A. Assess the client's peripheral pulses every 15 min. Frequent assessment of peripheral pulses, especially in the affected extremity, is essential to monitor for signs of arterial occlusion, hematoma, or compromised circulation following a femoral catheterization.

B. Change the client's dressing 4 hr following the procedure. The initial pressure dressing should not be disturbed unless there are signs of bleeding or saturation. Routine dressing changes this soon can disrupt the clotting process at the insertion site.

C. Instruct the client to flex the right knee every 30 min. The client should keep the affected leg straight to prevent disrupting the insertion site. Flexing the knee can increase the risk of bleeding and compromise the integrity of the puncture site.

D. Elevate the head of the client's bed to 45°. Elevating the head of the bed too high can increase abdominal pressure on the femoral site, risking bleeding. The bed should be kept no higher than 30° to reduce stress on the insertion area.

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A nurse is teaching the parents of a toddler about booster seat safety. Which of the following instructions should the nurse include?

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Naxlex Comprehensive Predictor Exams

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Correct Answer is A

Explanation

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