Correct Answer: C

Rationale: During a tonic-clonic seizure, the priority nursing responsibility is to protect the child from self-injury. Applying restraints (
Choice
A) can cause harm by restricting movement during the seizure. While administering oxygen (
Choice
B) may be necessary, it is not the immediate priority during an active seizure. Inserting a plastic airway (
Choice
D) is contraindicated as it can lead to injury and is not recommended during a seizure. Protecting the child from self-injury (
Choice
C) is crucial to prevent harm from uncontrolled movements and potential falls, ensuring the safety of the child.

Correct Answer: B

Rationale: The priority nursing intervention for a child with acute lymphoblastic leukemia (ALL) is preventing infection due to their compromised immune system. Children undergoing treatment for ALL are highly susceptible to infections, making infection prevention crucial for the child's well-being and treatment success. Administering antibiotics, though important in specific cases, is not the priority in this scenario. Providing nutritional support and managing pain are significant aspects of care but take a back seat to infection prevention in this situation.

Correct Answer: C

Rationale: Placing the child in a semi-Fowler's position after eating is beneficial for reducing symptoms of gastroesophageal reflux. This position helps prevent gastric contents from flowing back into the esophagus. The supine position (choice
A) may worsen reflux symptoms by allowing gravity to assist in reflux, leading to discomfort and regurgitation. Prone position (choice
B) is not recommended after eating as it may cause discomfort and increase the risk of aspiration due to pressure on the stomach. Trendelenburg position (choice
D), with the head lower than the rest of the body, is not indicated for managing GERD after eating and may not provide the desired benefits in this context.

Correct Answer: C

Rationale: In a severe asthma attack, the child is likely to develop respiratory acidosis. This occurs due to impaired respirations, leading to the retention of carbon dioxide and the formation of carbonic acid.
Choice A is incorrect as metabolic alkalosis is not expected in this situation.
Choice B is incorrect as respiratory alkalosis does not align with the scenario of impaired respirations in severe asthma attacks.
Choice D is also incorrect as it describes metabolic acidosis, which is not typically associated with severe asthma attacks.

Correct Answer: D

Rationale: The correct answer is to test the temperature of water before bathing. This is crucial in preventing burns, which is a significant risk for infants due to their sensitive skin. Infants have delicate skin that can be easily burned by water that is too hot. Removing small objects from the floor (
Choice
A) is important to prevent choking hazards but not directly related to burns. Covering electric outlets with safety plugs (
Choice
B) is essential to prevent electrocution but does not address the risk of burns specifically. Removing toxic substances from low areas (
Choice
C) is necessary to prevent poisoning but is not directly related to burns.
Therefore, the priority in this scenario is to prevent burns by ensuring the water temperature is safe for the infant.