A pediatric nurse is caring for multiple clients and reviewing each of their care plans. Which of the following client care interventions requires revising?
Administer a bronchodilator two times a day for a child who has cystic fibrosis.
Check the neurovascular status every 4 hr of a child who had a hip spica cast placed 6 hr ago
Maintain eye shields for a newborn receiving phototherapy for hyperbilirubinemia.
Teach an adolescent who has an exacerbation of ulcerative colitis about a high-protein, low-fiber diet
The Correct Answer is D
Choice A reason: Administering a bronchodilator two times a day for a child who has cystic fibrosis is an appropriate intervention, as it helps to improve the child's respiratory function and prevent mucus accumulation.
Choice B reason: Checking the neurovascular status every 4 hr of a child who had a hip spica cast placed 6 hr ago is an appropriate intervention, as it helps to monitor the child's circulation and nerve function and detect any signs of compartment syndrome.
Choice C reason: Maintaining eye shields for a newborn receiving phototherapy for hyperbilirubinemia is an appropriate intervention, as it helps to protect the newborn's eyes from the harmful effects of the light and prevent eye damage.
Choice D reason: Teaching an adolescent who has an exacerbation of ulcerative colitis about a high-protein, low-fiber diet is an incorrect intervention, as it contradicts the dietary recommendations for this condition. A high-protein, low-fiber diet can worsen the inflammation and symptoms of ulcerative colitis. The nurse should teach the adolescent about a low-residue, high-calorie, high-protein diet instead.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
Choice A reason: Returning unused supplies from the bedside to the unit's supply stock is an appropriate action to include in the cost-containment plan. This action prevents waste and saves money by reusing the supplies that are not contaminated or expired.
Choice B reason: Using clean gloves rather than sterile gloves for colostomy care is not an appropriate action to include in the cost-containment plan. This action compromises the quality and safety of care by increasing the risk of infection and cross-contamination. Sterile gloves are required for colostomy care to prevent introducing microorganisms into the stoma or the pouch.
Choice C reason: Storing opened bottles of normal saline in a refrigerator for up to 48 hours is not an appropriate action to include in the cost-containment plan. This action violates the infection control and medication administration policies. Opened bottles of normal saline should be discarded after 24 hours or after a single use, depending on the facility's protocol. Refrigerating the bottles does not extend their shelf life or sterility.
Choice D reason: Waiting to dispose of sharps containers until they are completely full is not an appropriate action to include in the cost-containment plan. This action poses a hazard and a liability for the staff and the clients. Sharps containers should be disposed of when they are three-quarters full or according to the manufacturer's instructions. Overfilling the containers can cause needlestick injuries or spillage of contaminated materials.
Correct Answer is B
Explanation
Choice A reason: Candidiasis is not a reportable infection. It is a fungal infection that causes vaginal itching and discharge. It is not a sexually transmitted infection, but it can occur after antibiotic use or hormonal changes.
Choice B reason: Gonorrhea is a reportable infection. It is a bacterial infection that causes genital discharge, pain, and bleeding. It can also spread to other parts of the body and cause serious complications. It is a sexually transmitted infection that can be prevented by using condoms and treated with antibiotics.
Choice C reason: Human papillomavirus is not a reportable infection. It is a viral infection that causes genital warts and cervical cancer. It is a sexually transmitted infection that can be prevented by using condoms and getting vaccinated.
Choice D reason: Trichomoniasis is not a reportable infection. It is a parasitic infection that causes vaginal itching, burning, and odor. It is a sexually transmitted infection that can be treated with antiparasitic drugs.
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