a 4 year old child is scheduled for a myringotomy what should the nurse include in the preoperative teaching
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Pediatric HESI Test Bank

1. What should the nurse include in the preoperative teaching for a 4-year-old child scheduled for a myringotomy?

Correct answer: A

Rationale: For a 4-year-old child scheduled for a myringotomy, explaining the procedure in simple terms is essential in helping the child understand what will happen during the surgery and reducing anxiety. Encouraging fluid intake, allowing the child to play with medical equipment, and using play therapy are not directly related to preparing the child for the myringotomy procedure. Therefore, these options are incorrect and not as beneficial as explaining the procedure in simple terms.

2. What is the most appropriate method to feed an infant born with a unilateral cleft lip and palate?

Correct answer: B

Rationale: A cross-cut nipple is the most appropriate method to feed an infant born with a unilateral cleft lip and palate. Using a cross-cut nipple allows for easier feeding by modifying the flow of milk, which helps in reducing the risk of aspiration in infants with this condition. Plastic spoon, parenteral infusion, and rubber-tipped syringe are not suitable for feeding infants with cleft lip and palate. Feeding an infant with a cleft lip and palate requires special considerations to ensure safe and effective nutrition delivery.

3. What is the most common cause of shock (hypoperfusion) in infants and children?

Correct answer: A

Rationale: Infection is the most common cause of shock in infants and children due to their increased susceptibility to sepsis. Infants and children have underdeveloped immune systems, making them more prone to infections that can lead to septic shock. While cardiac failure is a serious condition, it is not the most common cause of shock in this population. Accidental poisoning, though dangerous, is less common than infection in causing shock in infants and children. Severe allergic reactions can lead to anaphylactic shock, but they are not as prevalent as infections in causing shock in this age group.

4. A child with a diagnosis of diabetes insipidus is admitted to the hospital. What is the priority nursing intervention?

Correct answer: B

Rationale: The correct priority nursing intervention for a child diagnosed with diabetes insipidus is to monitor fluid balance. Diabetes insipidus is a condition characterized by excessive urination and thirst, which can lead to dehydration. Monitoring fluid balance is essential to prevent dehydration and ensure the child's hydration status remains stable. Administering insulin (Choice A) is not indicated in diabetes insipidus because it is a disorder of the posterior pituitary gland, not the pancreas. Administering diuretics (Choice C) would exacerbate fluid loss in a child already at risk for dehydration. Monitoring vital signs (Choice D) is important but not the priority when compared to maintaining fluid balance in a child with diabetes insipidus.

5. A 4-year-old child is admitted to the hospital with a diagnosis of epiglottitis. What is the priority nursing intervention?

Correct answer: C

Rationale: The priority nursing intervention for a 4-year-old child admitted to the hospital with epiglottitis is to keep the child NPO (nothing by mouth). Epiglottitis is a serious condition that can lead to airway obstruction. Keeping the child NPO helps prevent further compromise of the airway and reduces the risk of aspiration. Administering antibiotics may be necessary but ensuring the airway is not compromised takes precedence. Providing humidified oxygen is important for respiratory support, but not the priority over maintaining a patent airway. Positioning the child upright can help with breathing and comfort, but it does not directly address the immediate risk of airway compromise associated with epiglottitis.

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