a home care nurse is visiting a family for the first time the 4 week old infant had surgery for exstrophy of the bladder and creation of an ileal cond
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HESI Pediatrics Quizlet

1. A home care nurse is visiting a family for the first time. The 4-week-old infant had surgery for exstrophy of the bladder and creation of an ileal conduit soon after birth. When the nurse arrives, the mother appears tired, and the baby is crying. After an introduction, which is the most appropriate statement by the nurse?

Correct answer: A

Rationale: Asking about the daily routine is the most appropriate statement by the nurse in this scenario. It allows the nurse to gather important information about the family's schedule, feeding patterns, and overall care routine for the infant. This open-ended question helps the nurse assess the family's situation comprehensively and identify any areas where support may be needed. Choices B, C, and D are less appropriate as they do not focus on gathering relevant information about the family's routine and needs but rather make assumptions or ask about specific isolated events.

2. A nurse is providing care to a child with a diagnosis of bronchiolitis. What is the priority nursing intervention?

Correct answer: B

Rationale: The correct answer is providing respiratory therapy. In bronchiolitis, the priority is to maintain airway patency through interventions such as suctioning, positioning, and oxygen therapy. While bronchodilators may be used in some cases, they are not the initial priority. Monitoring oxygen saturation is important but comes after ensuring airway patency. Encouraging fluid intake is essential for hydration but is not the priority over maintaining a patent airway.

3. At 2 years of age, a child is readmitted to the hospital for additional surgery. What is the most important factor in preparing the toddler for this experience?

Correct answer: B

Rationale: The most important factor in preparing a toddler for additional surgery is their previous experience of hospitalization. This familiarity can help reduce anxiety and fear associated with the hospital environment and medical procedures. Choice A, satisfying the child’s wishes, may not always be feasible or in the child's best interest during medical procedures. Choice C, preventing the child from being with strangers, may not address the core issue of preparing the child for surgery. Choice D, ensuring the child still receives parental affection, is important but may not directly address the preparation needed for surgery.

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

Correct answer: B

Rationale: Encouraging deep breathing exercises is crucial preoperative teaching for a child scheduled for a tonsillectomy as it helps improve lung function and can prevent postoperative complications like pneumonia. Explaining the procedure in detail may heighten the child's anxiety, making it less ideal. While discussing hydration is important, it may not be the top priority for preoperative teaching for this specific procedure. Play therapy can reduce fear and anxiety, but encouraging deep breathing exercises directly contributes to better postoperative outcomes by enhancing respiratory function.

5. What explanation should the nurse provide to the parents of a 6-month-old infant diagnosed with cystic fibrosis?

Correct answer: A

Rationale: The correct answer is A. Cystic fibrosis is a genetic disorder that primarily affects the respiratory and digestive systems. It results in the production of thick, sticky mucus that can clog the lungs and obstruct the pancreas. This explanation is crucial for parents to understand the impact of the condition on their child's health. Choice B is incorrect because cystic fibrosis is not an autoimmune disorder. Choice C is partially correct in that cystic fibrosis is a genetic disorder, but it requires a comprehensive management approach beyond just medication. Choice D is incorrect as cystic fibrosis is not caused by prenatal exposure to toxins but rather by inheriting specific genetic mutations.

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