A nurse is discussing post-procedure interventions with new pediatric nurses. Which statement addresses the most immediate safety action required?

“Remove all equipment related to the procedure from the child’s environment.”

“Handle all contaminated linens in accordance with the facility policies.”

“Assess to ensure that the side rails are up and the bed is lowered to the floor.”

“Document the procedure and the response of the child as soon as the procedure is completed.”

Answer and Explanation

The Correct Answer is C

Choice A reason: Removing equipment reduces clutter but is less urgent than preventing falls, especially post-procedure when a child may be disoriented. Ensuring side rails and a low bed prioritizes safety, making this secondary and incorrect for the most immediate action in pediatric post-procedure care.

Choice B reason: Handling contaminated linens follows infection control but is not the immediate safety concern post-procedure. Preventing falls with side rails and a low bed is critical, making this less urgent and incorrect compared to the priority of ensuring the child’s physical safety after the procedure.

Choice C reason: Assessing side rails up and bed lowered prevents falls, the most immediate safety risk post-procedure when a child may be sedated or unsteady. This aligns with pediatric safety protocols, making it the correct statement for the most urgent action in post-procedure interventions.

Choice D reason: Documentation is essential but not immediate compared to fall prevention, which protects the child post-procedure. Side rails and bed positioning take precedence, making this subsequent and incorrect for the most urgent safety action required after a pediatric procedure in the hospital.

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Correct Answer is D

Explanation

Choice A reason: Suctioning removes secretions from the nose and mouth, a correct purpose. This statement reflects accurate understanding of the procedure’s goal, making it correct and not requiring further instruction, unlike the misconception about exclusive bulb syringe use in suctioning discussed in the seminar.

Choice B reason: Asking a child to cough before suctioning clears airways and is appropriate when feasible, showing correct knowledge. This does not indicate a need for instruction, making it incorrect compared to the incorrect limitation of suctioning to bulb syringes only in the student’s statement.

Choice C reason: Using sterile saline drops to loosen secretions is a standard practice in nasal suctioning, reflecting accurate technique. This statement is correct, making it incorrect for needing further instruction, unlike the erroneous restriction of suctioning to bulb syringes alone in the seminar discussion.

Choice D reason: Suctioning is not limited to bulb syringes; catheter or mechanical suction is used in clinical settings for deeper secretions. This statement reflects a misunderstanding, requiring further instruction on suctioning methods, aligning with pediatric nursing standards, making it the correct choice for additional teaching.

A. Gets upset when a babysitter is in charge, but will do what is asked by the babysitter. B. Tries to sweep up spilled cereal but cries when can’t do well. C. Refuses to hold anyone’s hand while crossing the street. D. Broke a dish but blamed it on a friend the caregivers don’t know.

Correct Answer is B

Explanation

Choice A reason: Complying with a babysitter despite being upset shows adaptability, not initiative, which involves self-directed tasks. Attempting to clean cereal reflects proactive behavior, making this less indicative and incorrect compared to an activity demonstrating the 4-year-old’s initiative in the developmental assessment.

Choice B reason: Trying to sweep spilled cereal and crying when failing demonstrates initiative, as the 4-year-old independently attempts a task, a hallmark of Erikson’s initiative stage. This aligns with pediatric developmental milestones, making it the correct activity to document for assessing the child’s growth and development status.

Choice C reason: Refusing to hold hands while crossing the street indicates defiance, not initiative, which involves purposeful self-started activities. Cleaning cereal better reflects initiative, making this incorrect, as it shows autonomy rather than the proactive behavior expected in the initiative stage of development.

Choice D reason: Blaming a broken dish on a fictional friend shows guilt avoidance, not initiative, which involves taking on tasks independently. Attempting a cleanup task is more indicative, making this incorrect compared to the proactive behavior of sweeping cereal in the 4-year-old’s developmental assessment.

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A nurse is discussing post-procedure interventions with new pediatric nurses. Which statement addresses the most immediate safety action required?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is presenting a post-conference seminar to a group of nursing students on the topic of suctioning of a child. Which statement made by a student demonstrates a need for further instruction on this procedure?

Correct Answer is D

Explanation

The pediatric nurse is discussing the daily activities of a 4-year-old with the caregiver to assess growth and development status. The nurse would document that the child has reached the initiative stage of development if the caregiver indicates the child participates in which activity?

Correct Answer is B

Explanation

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