Question

A nurse is preparing to apply lidocaine and prilocaine cream to a child prior to the insertion of an IV catheter.Which of the following actions should the nurse plan to take?

Answer 1

Correct Answers:

Apply the cream 1 hr. before the procedure

Rationale :

🕒Topical anesthetics such as lidocaine and prilocaine cream require adequate time to penetrate the skin and reach maximum effectiveness.

🧴Application should be done at least 1 hour prior to the procedure to ensure sufficient dermal absorption and local anesthetic effect.

🚫The nurse should not rub the cream into the skin, as this can alter absorption and increase the risk of skin irritation or systemic absorption.

🧼The area should be clean and dry, but not prepped with alcohol, as alcohol may cause stinging and affect the skin barrier.

🩹A transparent dressing is usually applied over the cream to keep it in place and ensure proper absorption until removal before the procedure.

📌Core Message

Apply lidocaine-prilocaine cream at least 1 hour before IV insertion to allow for maximum skin numbing and ensure a less painful procedure. Avoid rubbing or using alcohol before application.

Answer 2

Correct Answers:

Maintain an Ng tube for decompression

Rationale :

🧪Meckel diverticulum repair involves surgical correction of a congenital anomaly that can cause intestinal obstruction or bleeding.

🧷After surgery, it is essential to decompress the gastrointestinal tract using a nasogastric (NG) tube to prevent abdominal distention and reduce pressure on the surgical site.

🛌Postoperative care includes monitoring for signs of infection and bowel function return, but long-term antibiotics are not typically necessary unless complications arise.

🚫Ostomy care is not relevant unless there is a stoma, which is not a standard outcome of Meckel diverticulum repair.

📌Core Message

Post-op care for Meckel diverticulum repair includes NG tube decompression to support bowel rest and healing.

Answer 3

Correct Answers:

hyperpyrexia

Rationale :

🔥Acute acetylsalicylic acid (aspirin) poisoning causes central nervous system stimulation, which can lead to hyperpyrexia (very high fever).

🧪The overdose disrupts metabolic processes, particularly leading to metabolic acidosis, which further raises body temperature.

🧍This condition can present with vomiting, confusion, restlessness, tachypnea, and fever, especially in children.

🚫Jaundice, neck vein distension, and polyuria are not hallmark features of acute aspirin poisoning and suggest different diagnoses.

📌Core Message

Hyperpyrexia is a critical sign of aspirin toxicity due to CNS excitation and metabolic acidosis.

Answer 4

Correct Answers:

initiate bleeding precautions

Rationale :

🩸Children with acute lymphocytic leukemia (ALL) often experience thrombocytopenia due to bone marrow suppression, which increases bleeding risk.

🚫Procedures such as rectal temperatures or using hard toothbrushes should be avoided to reduce trauma to mucous membranes.

🧼Bleeding precautions include soft-bristle toothbrush use, avoiding injections when possible, and careful monitoring for petechiae or bruising.

🧃Viscous lidocaine is contraindicated in young children due to risk of aspiration and seizures if swallowed.

📌Core Message

Children with ALL must follow bleeding precautions because of their reduced platelet counts and fragile mucosal integrity.

Answer 5

Correct Answers:

Encourage the adolescent to perform incentive spirometry to maintain lung capacity

Rationale :

🫁Muscular dystrophy weakens skeletal and respiratory muscles, which compromises ventilation and lung expansion.

📈Incentive spirometry encourages deep breathing and maintains pulmonary function, reducing the risk of atelectasis.

💉Routine vaccines should be encouraged, not avoided, as infections can further worsen respiratory health.

🧴Excessive chest physiotherapy or unnecessary wheelchair use could reduce independence and isn’t preventive unless clinically indicated.

📌Core Message

Incentive spirometry preserves lung capacity in clients with progressive respiratory muscle weakness from muscular dystrophy.

Answer 6

Correct Answers:

Your child should walk the bicycle through intersections

Rationale :

🚸Walking the bicycle across intersections reduces the risk of accidents and improves visibility to drivers.

🚳Children are more vulnerable in intersections where rapid decisions are needed, so dismounting is safest.

🚴‍♂️Feet should be able to touch the ground while seated—elevation of 3–6 inches is not safe.

🚫Riding against traffic is dangerous; children should always ride with traffic and stay near the curb.

📌Core Message

Children should walk bicycles through intersections to improve safety and visibility in traffic environments.

Answer 7

Correct Answers:

Provide a pacifier coated with an oral sucrose prior to injections

Rationale :

🍬Oral sucrose has an analgesic effect in infants by promoting endogenous opioid release, making procedures like injections less distressing.

👶This method is simple, safe, and highly effective for atraumatic care in infants under 6 months.

💉The deltoid muscle is not appropriate for intramuscular injections in infants—vastus lateralis is preferred.

🧴EMLA cream needs to be applied 30–60 minutes in advance, so immediate application would not provide benefit.

📌Core Message

Oral sucrose with a pacifier provides safe, effective pain relief during immunizations for young infants.

Answer 8

Correct Answers:

Keep staff visits with the child brief

Rationale :

🤯Children with autism spectrum disorder (ASD) often experience sensory overload, so short, predictable interactions help reduce distress.

🧩Maintaining consistent routines is essential—unexpected changes or prolonged interactions can provoke anxiety or behavioral outbursts.

📺Leaving background noise like a TV on can increase overstimulation and confusion for a child with ASD.

🚫Semiprivate rooms expose the child to more uncontrolled stimuli, which may hinder progress or comfort.

📌Core Message

Children with autism benefit from brief, structured interactions and minimized sensory input to promote comfort and cooperation.

Answer 9

Correct Answers:

Sunken anterior fontanel

Rationale :

💧A sunken fontanel is a late and serious sign of severe dehydration in infants and signals urgent fluid loss.

⚠️Infants with heart failure are already hemodynamically vulnerable, so dehydration can quickly lead to shock or organ hypoperfusion.

📉Heart rate of 162/min is elevated but expected in distress; it is not as immediately life-threatening as dehydration signs.

🧪Potassium of 5.1 mEq/L is mildly elevated but would not take priority unless associated with ECG changes.

📌Core Message

A sunken fontanel indicates severe dehydration and requires immediate fluid management in vulnerable infants.

Answer 10

Correct Answers:

I will elevate my broken arm on pillows a tonight

Rationale :

🛏️Elevation reduces swelling and pain, improving comfort and circulation during the early healing phase.

🖐️Movement of fingers is encouraged to maintain mobility and prevent stiffness, not restricted.

🚫Persistent swelling should not be expected for several days and may indicate compartment syndrome.

💨Baby powder inside a cast can trap moisture, leading to skin breakdown or infection.

📌Core Message

Elevation of a casted limb reduces swelling and discomfort and promotes better circulation during recovery.

1 :
A nurse is preparing to apply lidocaine and prilocaine cream to a child prior to the insertion of an IV catheter.Which of the following actions should the nurse plan to take?

2 :
A nurse is planning care for an adolescent following repair of Meckel Diverticulum.Which of the following actions should the nurse include in the plan of care?

3 :
A nurse in an emergency department is caring for a preschool- age child who has acute acetylsalicylic acid poisoning. Which of the following should the nurse expect?

4 :
A nurse is reviewing the medical record of a 24-month-old child who has acute lymphocytic leukemia.Which of the following actions should the nurse take?

5 :
A nurse is creating a plan of care for an adolescent who has muscular dystrophy.Which of the following interventions should the nurse include in the plan?

6 :
A nurse is teaching the parent of a school-age child about bicycle safety. Which of the following instructions should the nurse include in the teaching?

7 :
A nurse is preparing to administer immunizations to a 3- month-old infant. Which of the following is an appropriate action for the nurse to take to deliver atraumatic care?

8 :
A nurse at an inpatient facility is planning care for a child who has autism spectrum disorder. Which of the following interventions should the nurse include in the plan of care?

9 :
A nurse is caring for a 2-month-old infant who has heart failure and is receiving furosemide. Which of the following findings is the nurse's priority?

10 :
A nurse is educating an adolescent following this application of an arm cast. Which of the following statements by the client indicates an understanding of the teaching?

1 : A nurse is preparing to apply lidocaine and prilocaine cream to a child prior to the insertion of an IV catheter.Which of the following actions should the nurse plan to take?

2 : A nurse is planning care for an adolescent following repair of Meckel Diverticulum.Which of the following actions should the nurse include in the plan of care?

3 : A nurse in an emergency department is caring for a preschool- age child who has acute acetylsalicylic acid poisoning. Which of the following should the nurse expect?

4 : A nurse is reviewing the medical record of a 24-month-old child who has acute lymphocytic leukemia.Which of the following actions should the nurse take?

5 : A nurse is creating a plan of care for an adolescent who has muscular dystrophy.Which of the following interventions should the nurse include in the plan?

6 : A nurse is teaching the parent of a school-age child about bicycle safety. Which of the following instructions should the nurse include in the teaching?

7 : A nurse is preparing to administer immunizations to a 3- month-old infant. Which of the following is an appropriate action for the nurse to take to deliver atraumatic care?

8 : A nurse at an inpatient facility is planning care for a child who has autism spectrum disorder. Which of the following interventions should the nurse include in the plan of care?

9 : A nurse is caring for a 2-month-old infant who has heart failure and is receiving furosemide. Which of the following findings is the nurse's priority?

10 : A nurse is educating an adolescent following this application of an arm cast. Which of the following statements by the client indicates an understanding of the teaching?

1 :
A nurse is preparing to apply lidocaine and prilocaine cream to a child prior to the insertion of an IV catheter.Which of the following actions should the nurse plan to take?

2 :
A nurse is planning care for an adolescent following repair of Meckel Diverticulum.Which of the following actions should the nurse include in the plan of care?

3 :
A nurse in an emergency department is caring for a preschool- age child who has acute acetylsalicylic acid poisoning. Which of the following should the nurse expect?

4 :
A nurse is reviewing the medical record of a 24-month-old child who has acute lymphocytic leukemia.Which of the following actions should the nurse take?

5 :
A nurse is creating a plan of care for an adolescent who has muscular dystrophy.Which of the following interventions should the nurse include in the plan?

6 :
A nurse is teaching the parent of a school-age child about bicycle safety. Which of the following instructions should the nurse include in the teaching?

7 :
A nurse is preparing to administer immunizations to a 3- month-old infant. Which of the following is an appropriate action for the nurse to take to deliver atraumatic care?

8 :
A nurse at an inpatient facility is planning care for a child who has autism spectrum disorder. Which of the following interventions should the nurse include in the plan of care?

9 :
A nurse is caring for a 2-month-old infant who has heart failure and is receiving furosemide. Which of the following findings is the nurse's priority?

10 :
A nurse is educating an adolescent following this application of an arm cast. Which of the following statements by the client indicates an understanding of the teaching?