The nurse is completing an admission assessment on a 3-year-old ...

[Alainaaa8]

The nurse is completing an admission assessment on a 3-year-old child. The child's Humpty Dumpty score is 15. Which action by the nurse is the most appropriate?
 
  A.
  Allow the child access to the play room.
  B.
  Classify the child as at high risk for falls.
  C.
  Place the child on seizure precautions.
  D.
  Put the child in isolation precautions.

Question 2

Prior to administering IV chemotherapy, which action by the nurse is most important?
 
  A.
  Ensure the IV has a good blood return.
  B.
  Provide diversionary activities.
  C.
  Take and record a set of vital signs.
  D.
  Weigh the child.

[TINA]

Answer to Question 1

ANS: B
A Humpty Dumpty score of 12 or above indicates a high risk for falls. The child has been classified as at high risk for falls, and nursing care should be implemented to prevent them. Access to the play room can be accomplished with almost any child. Seizures and isolation actions are not related.

Answer to Question 2

ANS: A
To prevent extravasation of IV chemotherapy it is important to make sure the line flushes easily and has a good blood return. This is a critical action to maintain patient safety. The other actions may also be utilized, but would not take priority over ensuring patient safety.