A nurse is teaching the parents of a toddler about booster seat safety. Which of the following instructions should the nurse include?

Place the booster seat where there is an air bag in the vehicle.

Avoid using the lap shoulder belt when the child is in a booster seat.

Use a no-back booster seat if the vehicle seat has a headrest.

Keep the booster seat rear-facing until the child weighs at least 16 kg (35.3 lb

Answer and Explanation

The Correct Answer is C

A. Place the booster seat where there is an air bag in the vehicle. Booster seats should never be placed in front of an active air bag, especially in the front seat. Air bags can cause serious injury or death to young children in the event of deployment.
B. Avoid using the lap shoulder belt when the child is in a booster seat. A lap-shoulder belt is required for proper use of a booster seat. The shoulder belt helps distribute force across the child’s chest and shoulders in a crash. Using only a lap belt increases the risk of serious abdominal and spinal injuries.
C. Use a no-back booster seat if the vehicle seat has a headrest. This is correct and safe. A no-back booster is appropriate as long as the vehicle seat has a high back or headrest that provides support for the child’s neck and head, ensuring proper positioning of the seat belt.
D. Keep the booster seat rear-facing until the child weighs at least 16 kg (35.3 lb). Booster seats are designed for forward-facing children who have outgrown a forward-facing harness seat, typically around 4 years of age and 40 pounds. Rear-facing seats are used prior to booster seats, for infants and toddlers, not for booster seat-age children.

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

Explanation

A. Ensure the formula is cold before administration. Enteral formula should be given at room temperature to avoid causing gastrointestinal cramping or discomfort. Cold formula can irritate the GI tract and lead to intolerance.
B. Check placement of the feeding tube by x-ray once daily. An x-ray is used initially to confirm tube placement after insertion, but daily x-rays are not required. Ongoing checks are done through aspirate checks and measuring external tube length.
C. Maintain the head of the client's bed at a 20° angle or higher. The head of the bed should be elevated to at least 30 to 45 degrees to prevent aspiration. A 20° angle is insufficient and increases the risk of aspiration pneumonia.
D. Check gastric residuals every 4 hr. This is appropriate for clients receiving continuous feedings. Monitoring gastric residual volume (GRV) every 4 hours helps assess tolerance to the feeding and reduces the risk of aspiration.
E. Change the feeding container and tubing every 24 hr. To prevent bacterial contamination, the feeding bag and tubing should be changed every 24 hours when using an open system. This is a standard infection control practice.

A. Offer the client saltine crackers between meals. B. Suggest rinsing his mouth with an alcohol based mouth wash. C. Instruct the client on the use of oesophageal speech. D. Provide humidification of the room air.

Correct Answer is D

Explanation

A. Offer the client saltine crackers between meals. Saltine crackers are dry and salty, which can worsen symptoms of xerostomia (dry mouth) by further irritating and drying the oral mucosa. Moist, soft foods are more appropriate.
B. Suggest rinsing his mouth with an alcohol-based mouth wash. Alcohol-based mouthwashes should be avoided in clients with dry mouth as they can exacerbate oral dryness and irritation. Alcohol-free rinses are recommended instead.
C. Instruct the client on the use of esophageal speech. Esophageal speech is used in clients who have had laryngectomies, not those experiencing xerostomia. This intervention is unrelated to the client's current condition.
D. Provide humidification of the room air. Using a humidifier adds moisture to the environment, which helps relieve oral dryness and makes the client more comfortable, especially during sleep or in dry indoor climates.

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A nurse is teaching the parents of a toddler about booster seat safety. Which of the following instructions should the nurse include?

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