Review Safety measures

Nursing Care of Hospitalized Children > Pediatrics

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Safety measures

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Total Questions : 6

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Question 1:

A nurse is caring for a 4-year-old child who is admitted to the hospital for pneumonia. The nurse observes that the child is restless, agitated, and frequently tries to get out of bed. What is the most appropriate nursing intervention to prevent falls in this child?

A. Apply a vest restraint to the child and secure it to the bed frame. B. Place a bed alarm on the child's mattress and lower the bed rails. C. Move the child to a room closer to the nurses' station and check on him frequently. D. Involve the child in diversionary activities and encourage parental supervision.

Answer and Explanation

Choice A:

This is not the appropriate nursing intervention, as it may increase the risk of injury, agitation, or psychological trauma in the child. Restraints should only be used as a last resort and with a physician's order.

Choice B:

This is not the appropriate nursing intervention, as it may not prevent the child from falling out of bed or wandering around the unit. Bed alarms are useful for alerting the staff, but they do not stop the child from moving.

Choice C:

This is a possible nursing intervention, as it may facilitate closer observation and monitoring of the child. However, it may not address the underlying cause of the child's restlessness or agitation.

Choice D:

This is the most appropriate nursing intervention, as it may reduce the child's boredom, anxiety, or fear and provide a sense of security and comfort. Diversionary activities may include toys, games, books, or music that are suitable for the child's age and developmental level. Parental supervision may also help prevent falls by assisting the child with toileting, positioning, or ambulation.

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Question 2:

A nurse is preparing to administer medication to a 6-month-old infant who has an ear infection. What actions should the nurse take to prevent medication errors in this patient? (Select all that apply.)

A. Check the medication label against the medication administration record (MAR) three times before giving the medication. B. Use an oral syringe or dropper to measure and administer liquid medication. C. Ask another nurse to verify the medication dosage and calculation. D. Compare the infant's identification band with the MAR and ask the parent to confirm the infant's name. E. Crush or dissolve any tablets or capsules and mix them with formula or juice.

Answer and Explanation

Choice A:

This action should be taken by the nurse to prevent medication errors, as it helps ensure that the medication is correct in terms of name, dose, route, time, and patient.

Choice B:

This action should be taken by the nurse to prevent medication errors, as it helps ensure that the medication is measured and administered accurately and safely. Oral syringes or droppers are more precise and easier to use than cups or spoons for liquid medication.

Choice C:

This action should be taken by the nurse to prevent medication errors, as it helps ensure that the medication dosage and calculation are correct and appropriate for the patient's weight and age. Another nurse can act as a double-check and catch any potential errors or discrepancies.

Choice D:

This action should be taken by the nurse to prevent medication errors, as it helps ensure that the medication is given to the right patient. Comparing the infant's identification band with the MAR and asking the parent to confirm the infant's name are two ways of verifying the patient's identity.

Choice E:

This action should not be taken by the nurse to prevent medication errors, as it may alter the effectiveness, absorption, or taste of the medication. Crushing or dissolving tablets or capsules and mixing them with formula or juice may also cause choking or aspiration in infants. The nurse should only administer medications that are in liquid form or prescribed to be crushed or dissolved.

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Question 3:

A nurse is caring for a child who has a central venous catheter (CVC) in place. What type of equipment-related injury is the child most at risk for and what action should the nurse take to prevent it?

A. Malfunction: the nurse should check the CVC for patency, integrity, and position regularly and report any problems to the physician. B. Misuse: the nurse should only use the CVC for the intended purpose and follow the manufacturer's instructions and protocols. C. Disconnection: the nurse should secure the CVC connections with tape or clamps and monitor the child for signs of bleeding or air embolism. D. Entanglement: the nurse should organize the CVC tubing and keep it away from the child's reach and movement.

Answer and Explanation

Choice A:

Choice A reason: This is not the correct answer, as malfunction is not the most common type of equipment-related injury for a child who has a CVC. Malfunction may occur due to mechanical failure, occlusion, infection, or thrombosis of the CVC, but it can be prevented or detected by regular assessment and maintenance of the CVC.

Choice B:

Choice B reason: This is not the correct answer, as misuse is not the most common type of equipment-related injury for a child who has a CVC. Misuse may occur due to human error, lack of knowledge, or inappropriate use of the CVC, but it can be prevented or corrected by following the standard guidelines and policies for CVC care.

Choice C:

Choice C reason: This is the correct answer, as disconnection is the most common type of equipment-related injury for a child who has a CVC. Disconnection may occur due to accidental removal, breakage, or loosening of the CVC connections, and it can cause serious complications such as hemorrhage or air embolism. The nurse should secure the CVC connections with tape or clamps and monitor the child for signs of bleeding or air embolism, such as hypotension, tachycardia, dyspnea, chest pain, cyanosis, or altered mental status.

Choice D:

Choice D reason: This is not the correct answer, as entanglement is not the most common type of equipment-related injury for a child who has a CVC. Entanglement may occur due to excessive or tangled tubing that can interfere with the child's mobility or comfort, but it can be prevented or minimized by organizing the tubing and keeping it away from the child's reach and movement.

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Question 4:

A nurse is performing a lumbar puncture on a child who has suspected meningitis. What statement by the nurse would indicate that the procedure is done correctly and safely?

A. "I will insert the needle between the third and fourth lumbar vertebrae and collect the cerebrospinal fluid." B. "I will position you on your side with your knees drawn up to your chest and your chin tucked to your chest." C. "I will apply a sterile dressing to the puncture site and monitor you for any signs of infection or bleeding." D. "I will give you some pain medication before the procedure and ask you to report any pain or discomfort during the procedure."

Answer and Explanation

Choice A:

This statement by the nurse would not indicate that the procedure is done correctly and safely, as it does not describe the correct anatomical landmark for a lumbar puncture. The needle should be inserted between the fourth and fifth lumbar vertebrae, not the third and fourth, to avoid damaging the spinal cord.

Choice B:

This statement by the nurse would indicate that the procedure is done correctly and safely, as it describes the correct position for a lumbar puncture. The lateral recumbent position with flexion of the spine helps expose the intervertebral spaces and facilitate the insertion of the needle.

Choice C:

This statement by the nurse would not indicate that the procedure is done correctly and safely, as it describes the post-procedure care, not the procedure itself. Applying a sterile dressing and monitoring for signs of infection or bleeding are important steps to prevent complications after a lumbar puncture, but they do not ensure that the procedure is done correctly and safely.

Choice D:

This statement by the nurse would not indicate that the procedure is done correctly and safely, as it describes the pre-procedure and intra-procedure care, not the procedure itself. Giving pain medication and asking for pain or discomfort are important steps to reduce anxiety and discomfort during a lumbar puncture, but they do not ensure that the procedure is done correctly and safely.

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Question 5:

A nurse is caring for a child who has a burn injury on the left arm. What type of procedure-related injury is the child most at risk for and what action should the nurse take to prevent it?

A. Pain: the nurse should assess the child's pain level and administer analgesics as prescribed. B. Bleeding: the nurse should apply pressure dressing to the wound and monitor the child's vital signs and hemoglobin level. C. Infection: the nurse should clean and dress the wound with sterile technique and monitor the child's temperature and white blood cell count. D. Allergic reaction: the nurse should ask the child and family about any history of allergies and observe the child for signs of rash, itching, or swelling.

Answer and Explanation

Choice A:

Choice A reason: This is not the correct answer, as pain is not the most common type of procedure-related injury for a child who has a burn injury. Pain is an expected outcome of a burn injury and its treatment, but it can be managed with appropriate analgesics and non-pharmacological interventions.

Choice B:

Choice B reason: This is not the correct answer, as bleeding is not the most common type of procedure-related injury for a child who has a burn injury. Bleeding may occur during debridement or grafting of the wound, but it can be controlled with pressure dressing and hemostatic agents.

Choice C:

Choice C reason: This is the correct answer, as infection is the most common type of procedure-related injury for a child who has a burn injury. Infection may occur due to loss of skin barrier, exposure to microorganisms, or impaired immune response. The nurse should clean and dress the wound with sterile technique and monitor the child's temperature and white blood cell count to prevent or detect infection.

Choice D:

Choice D reason: This is not the correct answer, as allergic reaction is not the most common type of procedure-related injury for a child who has a burn injury. Allergic reaction may occur due to hypersensitivity to medications, dressings, or grafts, but it can be prevented or treated with antihistamines or corticosteroids.

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Question 6:

A nurse is caring for a child who has a fractured femur and is in traction. Which of the following actions should the nurse take to prevent equipment-related injuries in this child?

A. Check the alignment and position of the traction and weights regularly. B. Inspect the skin under the traction device for signs of pressure or irritation. C. Assess the neurovascular status of the affected extremity frequently. D. All of the above.

Answer and Explanation

Choice A:

This action should be taken by the nurse to prevent equipment-related injuries, as it helps ensure that the traction is effective and does not cause any complications such as nerve damage, muscle spasms, or skin breakdown.

Choice B:

This action should be taken by the nurse to prevent equipment-related injuries, as it helps prevent pressure ulcers, infection, or inflammation of the skin under the traction device.

Choice C:

This action should be taken by the nurse to prevent equipment-related injuries, as it helps assess the blood flow, sensation, and movement of the affected extremity and detect any signs of impaired circulation, nerve compression, or compartment syndrome. Questions on Types and examples of play and distraction techniques

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Total Questions : 6

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Safety measures

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