An infant with a congenital heart defect is being given gavage feedings. The parents ask the nurse why this is necessary. How should the nurse respond?
- A. It limits the chance of vomiting.
- B. It allows the feeding to be administered rapidly.
- C. The energy that would have been expended on sucking is conserved.
- D. The quantity of nutritional liquid can be regulated better than with a bottle.
Correct Answer: C
Rationale: Gavage feedings are necessary for infants with congenital heart defects to conserve the infant's energy by eliminating the need for sucking. This is important because sucking requires energy expenditure, which can be taxing for infants with cardiac defects. Choice A is incorrect as gavage feedings do not primarily limit the chance of vomiting. Choice B is incorrect because the speed of feeding administration is not the primary reason for using gavage feedings in this case. Choice D is incorrect as the regulation of the quantity of nutritional liquid is not the main purpose of gavage feedings in infants with congenital heart defects.
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A group of students is reviewing information about the various types of insulin used to treat type 1 diabetes. The students demonstrate understanding of the information when they identify which of these insulins as having the longest duration.
- A. Lispro
- B. Regular
- C. NPH
- D. Glargine
Correct Answer: D
Rationale: The correct answer is Glargine (Lantus) as it has the longest duration of action among the insulins listed, lasting 12 to 24 hours. Lispro (Humalog) and Regular (short-acting) insulins have shorter durations of action, typically lasting 3 to 6 hours. NPH (Neutral Protamine Hagedorn) insulin has an intermediate duration of action, lasting around 12 to 18 hours. Therefore, choices A, B, and C are incorrect in the context of insulin duration.
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: The priority nursing care after a cardiac catheterization in a 3-year-old is to monitor the site for bleeding. This is essential to promptly detect and manage any potential complications, such as hematoma or hemorrhage. Encouraging early ambulation, as mentioned in choice A, may not be safe immediately post-procedure and should be guided by the healthcare provider's instructions. Restricting fluids until blood pressure is stabilized, as in choice C, is not typically necessary after a cardiac catheterization. Comparing blood pressure in both lower extremities, as in choice D, is not the priority immediate nursing care following this procedure.
A healthcare provider is assessing a child with suspected pneumonia. What clinical manifestation is the healthcare provider likely to observe?
- A. Cough
- B. Diarrhea
- C. Rash
- D. Vomiting
Correct Answer: A
Rationale: When assessing a child with suspected pneumonia, a healthcare provider is likely to observe a cough as a common clinical manifestation. Pneumonia often presents with symptoms such as cough, fever, difficulty breathing, and chest pain. Choice B, diarrhea, is not typically associated with pneumonia. Choice C, rash, is not a common clinical manifestation of pneumonia. Choice D, vomiting, is also not a typical symptom of pneumonia. Therefore, the correct answer is A: Cough.
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?
- A. Meeting the child's wishes
- B. Previous hospitalization experience
- C. Preventing the child from staying with strangers
- D. Ensuring ongoing parental affection
Correct Answer: B
Rationale: The most important factor in preparing a toddler for additional surgery is their previous hospitalization experience. This familiarity with the hospital setting and procedures can help reduce anxiety and fear in the child. Choice A, meeting the child's wishes, may not always align with what is medically necessary or safe for the child. Choice C, preventing the child from staying with strangers, is important for general comfort but may not directly address the child's preparation for surgery. Choice D, ensuring ongoing parental affection, is crucial for emotional support but may not have the same impact as the child's previous hospitalization experience in preparing them for the surgery.
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.