A nurse is working with an assistive personnel (AP) to care for a group of clients on the pediatric unit. Which of the following tasks should the nurse have the AP perform first?
Check to see if the elbow restraint is in place for an infant who is postoperative from a surgical correction of a cleft palate.
Wash the hair of an adolescent who reports extreme fatigue and is scheduled for radiation therapy for the treatment of Hodgkin lymphoma.
Collect a stool sample for ova and parasites from a school-age child
Engage a toddler in play.
The Correct Answer is A
Rationale:
A. Check to see if the elbow restraint is in place for an infant who is postoperative from a surgical correction of a cleft palate is a priority to ensure the safety and proper positioning of a vulnerable postoperative patient.
B. Wash the hair of an adolescent who reports extreme fatigue and is scheduled for radiation therapy for the treatment of Hodgkin lymphoma can be done later, as it is not as critical as ensuring the safety of a postoperative infant.
C. Collect a stool sample for ova and parasites from a school-age child is important but not as urgent as checking restraints for a postoperative infant.
D. Engage a toddler in play is important for developmental support but is not as urgent as tasks directly related to patient safety and postoperative care.
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Related Questions
Correct Answer is D
Explanation
Rationale:
A. The nurse coats the indwelling urinary catheter with lubricant is correct and necessary for the procedure to reduce discomfort and facilitate insertion.
B. The nurse applies the sterile drape prior to inserting the urinary catheter is a proper step to maintain a sterile field during the procedure.
C. The nurse provides perineal care prior to inserting the urinary catheter is appropriate as it ensures cleanliness before catheter insertion.
D. The nurse separates the client's labia with her dominant hand should not be done; the non-dominant hand should be used to hold the labia apart to maintain sterility.
Correct Answer is D
Explanation
Rationale:
A. A staff nurse typically does not function as the incident commander; this role is usually filled by someone with a leadership or administrative position in disaster planning.
B. An actual disaster cannot replace a drill because drills are designed to prepare staff for specific scenarios and ensure readiness.
C. A physician is not required to triage victims; this task can be performed by trained triage nurses or other designated personnel.
D. Regular disaster drills are essential for ensuring preparedness and assessing the effectiveness of disaster response plans.
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