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?

“The purpose of this form of suctioning is to remove secretions from the nose and mouth.”

“If possible, the child should be asked to cough before suctioning.”

“Sterile normal saline drops are used to loosen the dried secretions prior to nasal suctioning.”

“Such suctioning is only done with a bulb syringe.”

Answer and Explanation

The Correct Answer is D

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.

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Correct Answer is C

Explanation

Choice A reason: Prescribing medication to calm an infant is premature without investigating the cause of restlessness and prolonged wakefulness. An in-depth assessment identifies underlying issues like medical or environmental factors, making this reactive and incorrect compared to a thorough evaluation of the infant’s behavior.

Choice B reason: Reporting to a supervisor is unnecessary before assessing the infant’s restlessness and wakefulness. Conducting an in-depth investigation allows the nurse to gather data on potential causes, making this less direct and incorrect compared to initiating a thorough assessment of the infant’s condition first.

Choice C reason: Restlessness and prolonged wakefulness in an infant warrant an in-depth investigation to identify causes like medical issues, feeding problems, or environmental factors. This aligns with pediatric nursing assessment principles, ensuring a comprehensive approach to the infant’s behavior, making it the correct response for the nurse.

Choice D reason: Assuming the behavior is normal because the mother reports it dismisses potential underlying issues causing restlessness. An in-depth investigation is needed to rule out medical or environmental factors, making this incorrect, as it risks overlooking conditions requiring intervention in the infant’s care.

A. Observe him for physical signs which might indicate pain. B. Ask him to show you his pain level using the color pain scale. C. Explain to his caregiver that his pain level shows he is getting better quickly. D. Tell him to let you know if he begins to feel pain.

Correct Answer is A

Explanation

Choice A reason: Observing for physical signs like grimacing or guarding ensures accurate pain assessment, as a 10-year-old may underreport pain. This aligns with pediatric pain assessment protocols, making it the prioritized intervention to verify the child’s claim of no pain post-appendectomy accurately.

Choice B reason: A color pain scale relies on the child’s verbal report, which may be unreliable if he’s minimizing pain. Observing physical signs is more objective, making this secondary and incorrect compared to the nurse’s priority of assessing for hidden pain in the post-surgical child.

Choice C reason: Explaining to the caregiver assumes no pain without objective assessment, risking missed discomfort. Observing physical signs confirms the child’s status, making this premature and incorrect compared to the nurse’s role in thoroughly assessing pain in the 10-year-old post-appendectomy.

Choice D reason: Asking the child to report pain later depends on his willingness, which may be inconsistent. Observing physical signs provides immediate data, making this passive and incorrect compared to the nurse’s priority of actively assessing for pain in the child post-appendectomy procedure.

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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?

Nursing Test Bank

Naxlex Comprehensive Predictor Exams

The nurse is observing an infant and notes that the infant is restless, wide-awake but quiet. The mother reports that her baby often is awake for hours at a time and is very fidgety. How would the nurse respond to her observation?

Correct Answer is C

Explanation

A 10-year-old boy who had an appendectomy had expressed worry that following the procedure he would have lots of pain. Two days after the procedure the child is claiming he is having no pain. Which nursing intervention should the nurse prioritize when assessing this child?

Correct Answer is A

Explanation

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