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After a cardiac catheterization, what is the priority nursing care for a 3-year-old child?
- A. Encouraging early ambulation
- B. Monitoring the site for bleeding
- C. Restricting fluids until the blood pressure is stabilized
- D. Comparing the blood pressure of both lower extremities
Correct Answer: B
Rationale: After a cardiac catheterization, the priority nursing care for a 3-year-old child is monitoring the site for bleeding. This is essential to promptly identify and address any signs of bleeding or hematoma formation, which are potential complications of the procedure. Encouraging early ambulation may be beneficial post-procedure but ensuring site integrity takes precedence. Restricting fluids until blood pressure stabilization is not a standard post-catheterization practice, as adequate hydration is crucial for recovery. Comparing the blood pressure of both lower extremities is not a priority immediate nursing action after a cardiac catheterization in a pediatric patient.
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A 3-year-old child with a history of frequent respiratory infections is being evaluated for cystic fibrosis. What diagnostic test should the nurse anticipate will be ordered?
- A. Chest X-ray
- B. Sweat chloride test
- C. Pulmonary function test
- D. Sputum culture
Correct Answer: B
Rationale: The correct answer is the sweat chloride test. This test is crucial in diagnosing cystic fibrosis as it measures the amount of chloride in sweat, which is typically elevated in individuals with cystic fibrosis. A chest X-ray (Choice A) may show characteristic findings like hyperinflation or bronchiectasis, but it is not a definitive diagnostic test for cystic fibrosis. Pulmonary function tests (Choice C) may help assess lung function but are not specific for cystic fibrosis. Sputum culture (Choice D) may be used to identify specific pathogens causing respiratory infections but is not a primary diagnostic test for cystic fibrosis.
The nurse is assisting low-income families to access health care. The nurse is aware that, in today's society, this most accurately defines the diversity of a modern family.
- A. A family consists of parents and their offspring living together.
- B. A family is whatever the child and family say it is.
- C. A family is two or more people related or unrelated who are living together.
- D. A family is two or more genetically related persons living together with separate roles.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The healthcare provider closely monitors the temperature of a child with minimal change nephrotic syndrome. The purpose of this assessment is to detect an early sign of which possible complication?
- A. infection
- B. hypertension
- C. encephalopathy
- D. edema
Correct Answer: A
Rationale: Monitoring the temperature of a child with minimal change nephrotic syndrome is crucial for detecting early signs of infection, a common complication in this condition. In nephrotic syndrome, the child's immune system is compromised, making them more susceptible to infections. Monitoring for fever or any changes in temperature can help healthcare providers intervene promptly to prevent further complications. Hypertension (choice B) is not typically associated with minimal change nephrotic syndrome. Encephalopathy (choice C) refers to brain dysfunction and is not a common complication of nephrotic syndrome. Edema (choice D) is a primary manifestation of nephrotic syndrome but is not typically monitored through temperature assessment.
What should be included in the nursing plan of care for a 6-month-old infant admitted to the pediatric unit with a diagnosis of respiratory syncytial virus (RSV)?
- A. Place the infant in a warm, dry environment.
- B. Allow parents and siblings to visit.
- C. Maintain standard and contact precautions.
- D. Administer prescribed antibiotics immediately.
Correct Answer: C
Rationale: The correct answer is C: Maintain standard and contact precautions. RSV is highly contagious, primarily spread through respiratory secretions. Therefore, it is crucial to implement infection control measures such as standard and contact precautions to prevent the spread of the virus to other patients, staff, and visitors. Choice A is incorrect because warmth and dryness are not specific interventions for RSV; the focus should be on infection control. Choice B may increase the risk of exposing others to RSV, so limiting visitors is recommended. Choice D is unnecessary because RSV is a viral infection, and antibiotics are not effective against viruses.
Following delivery of a newborn, the 21-year-old mother is experiencing mild vaginal bleeding. You note that her heart rate has increased from 90 to 120 beats/min and she is diaphoretic. Management should include
- A. oxygen, uterine massage, and transport
- B. oxygen, placement on the left side, and transport
- C. oxygen, treatment for shock, and uterus massage during transport
- D. oxygen, internal vaginal pads, and treatment of shock during transport
Correct Answer: C
Rationale: Postpartum hemorrhage can lead to shock due to excessive bleeding. Oxygen should be provided to support oxygenation. Treatment for shock, which includes maintaining vital signs and perfusion, is crucial. Uterine massage helps prevent further bleeding by promoting uterine contraction. This combination of interventions is essential for managing postpartum hemorrhage effectively. Choices A, B, and D lack the comprehensive approach needed for managing postpartum hemorrhage, as they do not address the treatment of shock, which is vital in this scenario.