A nurse is collecting data from a toddler during a well-child visit. Which of the following actions should the nurse take to prepare the toddler for a physical examination?

Allow the toddler to handle the equipment.

Thoroughly explain each procedure to the toddler.

Start the examination with routine immunizations.

Completely undress the toddler.

Answer and Explanation

The Correct Answer is A

Allowing the toddler to explore and handle the equipment, such as a stethoscope or blood pressure cuff, can help familiarize them with the objects and reduce anxiety. It can be done under the supervision of the nurse to ensure safety.

Starting the examination with routine immunizations can be helpful because it allows the child to get through potentially uncomfortable or distressing procedures early on. It can also create a positive association between the examination and a sense of relief after receiving vaccinations. While it is important to provide age-appropriate explanations to the toddler, it's essential to keep the explanations simple and concise. Using child-friendly language and demonstrating the procedure using dolls or toys can help the toddler understand what will happen during the examination.

Instead of completely undressing the toddler, it is generally more comfortable and less distressing to only partially undress them. For example, the nurse can ask the caregiver to remove the toddler's shirt while leaving the pants on. This approach helps maintain the child's sense of security and provides a level of modesty.

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Correct Answer is ["A","B","C","D"]

Explanation

Provide the client with written information about advance directives: It is important for the nurse to educate the client about advance directives, their purpose, and how they can make informed decisions about their healthcare.

Instruct the client that an advance directive is a legal document and must be honored by care providers: The nurse should explain to the client that an advance directive is a legally binding document that guides healthcare decisions, and it must be respected and followed by healthcare providers.

Communicate advance directives status via the medical record and shift report: The nurse should ensure that the client's advance directives status is accurately documented in the medical record and communicated to other members of the healthcare team during shift handoffs. This helps ensure that the client's wishes are known and respected by all involved in their care.

Initiate a power of attorney for health care document: The nurse can assist the client in initiating a power of attorney for healthcare document if the client wishes to appoint someone as their healthcare proxy or agent. This document designates someone to make medical decisions on behalf of the client if they become unable to do so.

The other options listed are not appropriate or accurate in relation to the responsibilities of the nurse regarding advance directives:

Document that the provider discussed-do-not-resuscitate status with the client: While discussing do-not-resuscitate (DNR) status may be part of the advance care planning process, it is not directly related to advance directives as a whole.

Inform the client that an advance directive discontinues further care: This statement is incorrect and misleading. An advance directive does not automatically discontinue care but rather guides the provision of care according to the client's wishes.

A. Obtain a complete blood count. B. Prepare client for insertion of 18-gauge peripheral IV prior to surgery. C. Administer Rh, D immune globulin prior to surgery. D. Explain the surgical procedure to the client. E. Verify consent form is signed by the client. F. Assist with administration of AB positive blood products if needed. G. Remind client to be NPO prior to surgery.

Correct Answer is ["A","B","C","E","G"]

Explanation

Based on the given information, the nurse should take the following actions in preparation for surgery:

Obtain a complete blood count: This is important to assess the client's hemoglobin, hematocrit, and other blood parameters before surgery.
Prepare the client for insertion of an 18-gauge peripheral IV prior to surgery: Adequate IV access is necessary for the administration of fluids and medications during and after surgery.
Administer Rh, D immune globulin prior to surgery: This action is indicated if the client is Rh-negative and there is a possibility of fetal-maternal blood mixing during the termination of pregnancy. Rh, D immune globulin is given to prevent sensitization to Rh-positive blood.
Verify consent form is signed by the client: Ensuring that the client has provided informed consent is essential before proceeding with any surgical intervention.
Remind the client to be NPO (nothing by mouth) prior to surgery: It is important for the client to have an empty stomach to reduce the risk of aspiration during anesthesia.

The following actions are not indicated based on the given information:

Explaining the surgical procedure to the client: Although it is important for the client to have an understanding of the procedure, this is typically done by the surgeon rather than the nurse.
Assisting with administration of AB positive blood products if needed: There is no indication of the need for blood products based on the information provided. Blood product administration would be determined based on the client's specific condition and surgical requirements.

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A nurse is collecting data from a toddler during a well-child visit. Which of the following actions should the nurse take to prepare the toddler for a physical examination?

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Naxlex Comprehensive Predictor Exams

A nurse is assisting with the care of a client. Laboratory Results 1100: Abdominal ultrasound: mass present in small intestine proximal to ileocecal valve. Size of mass is 6 cm x 7 cm (2.4 in x 2.8 in). Select the 4 responsibilities the nurse has in relation to the client's advance directives.

Correct Answer is ["A","B","C","D"]

Explanation

Exhibits The nurse is preparing the client for surgery. Which of the following actions should the nurse take? Select all that apply

Correct Answer is ["A","B","C","E","G"]

Explanation

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