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 A

Explanation

Choice A reason: The vastus lateralis is the preferred site for IM injections in infants, as it is well-developed, has minimal nerves and vessels, and accommodates safe volumes. This aligns with pediatric nursing injection guidelines, making it the best choice for a 3-month-old receiving an antibiotic intramuscularly.

Choice B reason: The deltoid muscle is underdeveloped in a 3-month-old, with insufficient muscle mass for safe IM injections. The vastus lateralis is safer and more developed, making this incorrect, as the deltoid risks injury or inadequate drug absorption in infants receiving intramuscular injections.

Choice C reason: The dorsogluteal muscle is avoided in infants due to proximity to the sciatic nerve and underdeveloped gluteal mass, risking nerve damage. The vastus lateralis is safer, making this incorrect for a 3-month-old, as it poses significant safety concerns for IM antibiotic injections.

Choice D reason: The ventrogluteal muscle is safe in older children but less accessible in infants due to small muscle mass and positioning challenges. The vastus lateralis is preferred for its accessibility and safety, making this incorrect for a 3-month-old’s IM antibiotic injection in clinical practice.

A. Discuss the client’s status with care options at the bedside. B. Keep a blood pressure cuff and stethoscope available at bedside. C. Supply mouth swabs for the family to moisten lips. D. Supply sufficient disposable pads to be placed under the client as needed. E. Provide pillows to facilitate the repositioning for comfort.

Correct Answer is ["C","D","E"]

Explanation

Choice A reason: Discussing care options involves clinical judgment, which is the nurse’s responsibility, not delegable to family. Providing comfort tasks like swabs or pads is appropriate, making this incorrect, as it involves professional decision-making unsuitable for family delegation in the adolescent’s care.

Choice B reason: Keeping medical equipment like a blood pressure cuff involves monitoring, a nursing task, not delegable to family. Comfort tasks like providing swabs or pillows are suitable, making this incorrect, as it requires clinical skills beyond family’s role in the terminally ill adolescent’s care.

Choice C reason: Supplying mouth swabs for lip moistening is a simple comfort task family can perform, promoting involvement and patient comfort. This aligns with pediatric palliative care delegation, making it a correct intervention to delegate to family for the terminally ill adolescent’s care.

Choice D reason: Providing disposable pads for hygiene is a non-clinical task family can manage, supporting dignity and comfort. This aligns with family involvement in palliative care, making it a correct intervention to delegate for the terminally ill adolescent’s care in the hospital setting.

Choice E reason: Supplying pillows for repositioning is a comfort-focused task family can handle, enhancing the adolescent’s well-being. This aligns with pediatric palliative care principles, making it a correct intervention to delegate to family members for the terminally ill adolescent’s hospital care.

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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 administering an intramuscular injection of an antibiotic to a 3-month-old infant. Which would be the best site for the nurse to give this medication?

Correct Answer is A

Explanation

The nurse is attempting to include family in the care of a hospitalized, terminally ill adolescent. Which interventions can be appropriately delegated to family members? (Select all that apply)

Correct Answer is ["C","D","E"]

Explanation

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