The nurse suspects a 3-year-old who is coughing vigorously has aspirated a small object. Which action should the nurse take?

Correct Answer: D

Rationale: In this scenario, the correct action for the nurse to take when suspecting a 3-year-old has aspirated a small object and is coughing vigorously is option D: Encourage the child to continue coughing. This is the correct choice because during choking incidents, coughing is the body's natural way of trying to dislodge the obstructing object. Encouraging the child to cough can help expel the object without the need for intervention that could potentially worsen the situation. Option A, delivering upward abdominal thrusts with a fisted hand (Heimlich maneuver), is not recommended for children under 1 year of age and may not be effective or safe for a 3-year-old. Option B, performing a blind finger sweep of the child's mouth, is also not recommended as it can push the object further down the airway. Option C, completing five rapid back blows between the shoulder blades, is indicated for conscious choking victims who are unable to cough, but in this case, encouraging the child to cough is the initial appropriate action. Educationally, it is crucial for healthcare providers to have a good understanding of first aid interventions for choking in pediatric patients. Training in pediatric basic life support (BLS) equips nurses with the knowledge and skills to respond effectively in emergency situations involving airway obstruction. By knowing the appropriate actions to take based on the age and condition of the child, nurses can provide timely and lifesaving care.

Correct Answer: B

Rationale: The correct answer is B) Use a bath sponge to cleanse the skin. This is not appropriate client education for preventing the spread of MRSA because bath sponges can harbor bacteria and spread infections. Option A is correct as avoiding contact sports can prevent the spread of MRSA to others. Option C is also correct as hand hygiene is crucial in preventing the transmission of MRSA. Option D, using an antibacterial soap when showering, is also appropriate as it can help reduce the bacterial load on the skin. Educationally, it is important to emphasize the proper hygiene practices to prevent the spread of MRSA, such as proper handwashing, avoiding sharing personal items, and keeping wounds covered. Teaching patients about these measures is crucial in preventing the spread of MRSA in healthcare settings and the community. Patients should be encouraged to follow evidence-based practices to protect themselves and others from infections like MRSA.

Correct Answer: B

Rationale: In this scenario, the correct answer is option B: "The client has a vase of fresh flowers on the table." The presence of fresh flowers in a room with a client who has reduced immunity can pose a risk of introducing pathogens and allergens, which could potentially harm the client's health. As a result, this observation requires immediate action by the nurse to remove the flowers and ensure a safe environment for the client. Option A, "The client is in a private room," is not the correct answer because having the client in a private room can actually be beneficial for infection control by reducing exposure to pathogens from other patients. Option C, "The client has a dedicated vital signs machine," is not the correct answer as this equipment being dedicated to the client indicates good infection control practices and does not pose a risk to the client's health. Option D, "There is hand sanitizer by the door," is not the correct answer as having hand sanitizer readily available is a good infection control measure and does not indicate immediate risk to the client's health. From an educational perspective, this question highlights the importance of infection control practices in healthcare settings, especially when caring for clients with reduced immunity. Nurses must be vigilant in identifying potential sources of infection and taking appropriate actions to mitigate risks and ensure the safety of their clients.

Correct Answer: B

Rationale: In this scenario, the correct answer is B) Assess the wound for signs of dehiscence. This is the appropriate next action because the sudden increase in blood-tinged drainage and popping sensation could indicate a potential wound complication like dehiscence, where the wound edges separate. By assessing the wound, the nurse can gather crucial information about the extent of the issue and determine the appropriate course of action. Option A) Send the client back to surgery is incorrect as it is an extreme measure that should only be considered if there is a severe complication that requires immediate surgical intervention, which is not evident at this point. Option C) Call the provider immediately is not the first step as the nurse should first assess the wound to provide the provider with a detailed report of the situation. Option D) Prepare to culture the wound is premature as wound culture is not the initial step in managing this situation. Assessing the wound for signs of dehiscence and any other complications should come first to guide further interventions. In an educational context, this question highlights the importance of prompt assessment and clinical judgment in post-operative care. Nurses need to be able to recognize signs of potential complications, prioritize actions based on assessment findings, and collaborate effectively with the healthcare team to provide optimal patient care.

Correct Answer: C

Rationale: In this scenario, the priority nursing intervention when a client arrives speaking only Spanish is to select option C, which is to request a medical interpreter. This is crucial for ensuring effective communication between the healthcare team and the client, which is essential for accurate assessment, diagnosis, and treatment. Without proper communication, there is a risk of misunderstanding important information, leading to potential errors in care delivery and compromising patient safety. Option A (Give the client a tour of the unit) is not the priority because communication needs to be established first to address the client's immediate healthcare needs. Option B (Verify the reason for admission) is important but can be done effectively only after effective communication is established. Option D (Call the chaplain for support) is not the priority in this situation as the immediate need is to ensure communication for providing safe and quality care to the client. From an educational perspective, this question highlights the significance of effective communication in nursing practice, especially in situations where language barriers exist. It emphasizes the importance of utilizing resources such as medical interpreters to facilitate communication and ensure patient-centered care. Nurses need to be prepared to address language barriers to provide holistic and culturally sensitive care to diverse patient populations.