Choice A reason: This is not the appropriate nursing intervention, as it may increase the risk of injury, agitation, or psychological trauma in the child. Restraints should only be used as a last resort and with a physician's order.

Choice B reason: This is not the appropriate nursing intervention, as it may not prevent the child from falling out of bed or wandering around the unit. Bed alarms are useful for alerting the staff, but they do not stop the child from moving.

Choice C reason: This is a possible nursing intervention, as it may facilitate closer observation and monitoring of the child. However, it may not address the underlying cause of the child's restlessness or agitation.

Choice D reason: This is the most appropriate nursing intervention, as it may reduce the child's boredom, anxiety, or fear and provide a sense of security and comfort. Diversionary activities may include toys, games, books, or music that are suitable for the child's age and developmental level. Parental supervision may also help prevent falls by assisting the child with toileting, positioning, or ambulation.

Choice A reason: This action should be taken by the nurse to prevent medication errors, as it helps ensure that the medication is correct in terms of name, dose, route, time, and patient.

Choice B reason: This action should be taken by the nurse to prevent medication errors, as it helps ensure that the medication is measured and administered accurately and safely. Oral syringes or droppers are more precise and easier to use than cups or spoons for liquid medication.

Choice C reason: This action should be taken by the nurse to prevent medication errors, as it helps ensure that the medication dosage and calculation are correct and appropriate for the patient's weight and age. Another nurse can act as a double-check and catch any potential errors or discrepancies.

Choice D reason: This action should be taken by the nurse to prevent medication errors, as it helps ensure that the medication is given to the right patient. Comparing the infant's identification band with the MAR and asking the parent to confirm the infant's name are two ways of verifying the patient's identity.

Choice E reason: This action should not be taken by the nurse to prevent medication errors, as it may alter the effectiveness, absorption, or taste of the medication. Crushing or dissolving tablets or capsules and mixing them with formula or juice may also cause choking or aspiration in infants. The nurse should only administer medications that are in liquid form or prescribed to be crushed or dissolved.

Choice A reason: This is not the correct answer, as the malfunction is not the most common type of equipment-related injury for a child who has a CVC. Malfunctions may occur due to mechanical failure, occlusion, infection, or thrombosis of the CVC, but it can be prevented or detected by regular assessment and maintenance of the CVC.

Choice B reason: This is not the correct answer, as misuse is not the most common type of equipment-related injury for a child who has a CVC. Misuse may occur due to human error, lack of knowledge, or inappropriate use of the CVC, but it can be prevented or corrected by following the standard guidelines and policies for CVC care.

Choice C reason: This is the correct answer, as disconnection is the most common type of equipment-related injury for a child who has a CVC. Disconnection may occur due to accidental removal, breakage, or loosening of the CVC connections, and it can cause serious complications such as hemorrhage or air embolism. The nurse should secure the CVC connections with tape or clamps and monitor the child for signs of bleeding or air embolism, such as hypotension, tachycardia, dyspnea, chest pain, cyanosis, or altered mental status.

Choice D reason: This is not the correct answer, as entanglement is not the most common type of equipment-related injury for a child who has a CVC. Entanglement may occur due to excessive or tangled tubing that can interfere with the child's mobility or comfort, but it can be prevented or minimized by organizing the tubing and keeping it away from the child's reach and movement.

Choice A reason: This statement by the nurse would not indicate that the procedure is done correctly and safely, as it does not describe the correct anatomical landmark for a lumbar puncture. The needle should be inserted between the fourth and fifth lumbar vertebrae, not the third and fourth, to avoid damaging the spinal cord.

Choice B reason: This statement by the nurse would indicate that the procedure is done correctly and safely, as it describes the correct position for a lumbar puncture. The lateral recumbent position with flexion of the spine helps expose the intervertebral spaces and facilitate the insertion of the needle.

Choice C reason: This statement by the nurse would not indicate that the procedure is done correctly and safely, as it describes the post-procedure care, not the procedure itself. Applying a sterile dressing and monitoring for signs of infection or bleeding are important steps to prevent complications after a lumbar puncture, but they do not ensure that the procedure is done correctly and safely.

Choice D reason: This statement by the nurse would not indicate that the procedure is done correctly and safely, as it describes the pre-procedure and intra-procedure care, not the procedure itself. Giving pain medication and asking for pain or discomfort are important steps to reduce anxiety and discomfort during a lumbar puncture, but they do not ensure that the procedure is done correctly and safely.

Choice A reason: This is not the correct answer, as pain is not the most common type of procedure-related injury for a child who has a burn injury. Pain is an expected outcome of a burn injury and its treatment, but it can be managed with appropriate analgesics and non-pharmacological interventions.

Choice B reason: This is not the correct answer, as bleeding is not the most common type of procedure-related injury for a child who has a burn injury. Bleeding may occur during debridement or grafting of the wound, but it can be controlled with pressure dressing and hemostatic agents.

Choice C reason: This is the correct answer, as infection is the most common type of procedure-related injury for a child who has a burn injury. Infection may occur due to loss of skin barrier, exposure to microorganisms, or impaired immune response. The nurse should clean and dress the wound with sterile technique and monitor the child's temperature and white blood cell count to prevent or detect infection.

Choice D reason: This is not the correct answer, as allergic reaction is not the most common type of procedure-related injury for a child who has a burn injury. Allergic reaction may occur due to hypersensitivity to medications, dressings, or grafts, but it can be prevented or treated with antihistamines or corticosteroids.

Choice A reason: This action should be taken by the nurse to prevent equipment-related injuries, as it helps ensure that the traction is effective and does not cause any complications such as nerve damage, muscle spasms, or skin breakdown.

Choice B reason: This action should be taken by the nurse to prevent equipment-related injuries, as it helps prevent pressure ulcers, infection, or inflammation of the skin under the traction device.

Choice C reason: This action should be taken by the nurse to prevent equipment-related injuries, as it helps assess the blood flow, sensation, and movement of the affected extremity and detect any signs of impaired circulation, nerve compression, or compartment syndrome.

Questions on Types and examples of play and distraction techniques