Nokea
A nurse is caring for a school-age child who has sickle cell anemia and is in vaso-occlusive crisis. Which of the following actions should the nurse take?
- A. Apply cold compresses to the affected areas.
- B. Prepare for a transfusion of platelets.
- C. Promote active range of motion exercises.
- D. Increase oral fluid intake.
Correct Answer: D
Rationale: The correct answer is D: Increase oral fluid intake. During a vaso-occlusive crisis in sickle cell anemia, there is a blockage of blood flow leading to tissue ischemia and pain. Increasing oral fluid intake helps to hydrate the child and improve blood flow, potentially reducing the severity of the crisis. Cold compresses (A) can worsen vasoconstriction, platelet transfusion (B) is not indicated for vaso-occlusive crisis, and active range of motion exercises (C) can exacerbate pain and further compromise blood flow. Increasing fluid intake is the most appropriate intervention to help manage the crisis.
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A nurse is caring for a 9-year-old child at a clinic. The nurse should determine that the assessment findings are consistent with which of the following conditions?
- A. Edema
- B. Ecchymosis
- C. Pain Level
- D. Sensation
Correct Answer: B
Rationale: The correct answer is B: Ecchymosis. Ecchymosis is the presence of bruising, which is commonly seen in cases of trauma such as sprains, fractures, and dislocations. In a 9-year-old child, ecchymosis may indicate underlying injury or trauma. Edema can also be present in sprains, fractures, and dislocations, but it is not specific to these conditions. Pain level is subjective and can vary depending on the individual, so it is not as definitive as ecchymosis in identifying a specific condition. Sensation is important to assess in cases of injury, but it is not as indicative of a specific condition as ecchymosis. Therefore, the presence of ecchymosis is the most specific assessment finding to determine the underlying condition in this case. (0, 1, 0)
A nurse is planning care for a child during admission to the facility. Which of the following actions should the nurse take first?
- A. Obtain a prescription for pain medication.
- B. Collect blood cultures.
- C. Transport the child to obtain a CT scan.
- D. Initiate seizure precautions.
Correct Answer: D
Rationale: The correct answer is D: Initiate seizure precautions. This should be the first action as it prioritizes the safety of the child. Seizure precautions involve ensuring a safe environment, such as removing any potential hazards and providing padding to prevent injury during a seizure. Collecting blood cultures (B) and obtaining a prescription for pain medication (A) can be important but are not as urgent as ensuring the child's safety in case of a seizure. Transporting the child for a CT scan (C) is not an immediate priority unless there is a critical need.
A nurse is caring for a 9-year-old at a clinic. The nurse reviews the assessment findings. Select findings that require immediate follow up. Select all that apply.
- A. Right forearm and fingers are edematous
- B. Abdomen non-distended
- C. Fingers slightly cool to touch
- D. Oxygen saturation 98% on room air
- E. Heart rate 102/min
- F. Respiratory rate 22/min
- G. Ecchymotic area noted on outer aspect of the forearm
Correct Answer: A,C,E,F
Rationale: The correct answers are A, C, E, and F.
A: Edematous right forearm and fingers can indicate a potential circulatory issue requiring immediate follow-up.
C: Fingers slightly cool to touch suggest poor circulation, requiring further assessment.
E: Heart rate of 102/min in a 9-year-old is above normal, indicating possible distress.
F: Respiratory rate of 22/min is slightly elevated and could indicate respiratory distress.
B, D, G are not immediate concerns as a non-distended abdomen, oxygen saturation of 98% on room air, and an ecchymotic area on the forearm do not require immediate follow-up in this context.
A nurse is caring for an infant who has coarctation of the aorta. Which of the following should the nurse identify as an expected finding?
- A. Weak femoral pulses
- B. Increased intracranial pressure
- C. Upper extremity hypotension
- D. Frequent nosebleeds
Correct Answer: A
Rationale: Correct Answer: A - Weak femoral pulses
Rationale: Coarctation of the aorta results in narrowing of the aorta, leading to decreased blood flow to the lower extremities. This causes weak or absent femoral pulses due to reduced blood supply. The other choices are incorrect as coarctation of the aorta typically does not directly cause increased intracranial pressure, upper extremity hypotension, or frequent nosebleeds. These symptoms are more commonly associated with other conditions such as head trauma, vascular issues, or nasal conditions.
A nurse is preparing to administer immunizations to a 5-year-old child who is up to date with the current immunization schedule. Which of the following immunizations should the nurse plan to administer?
- A. Haemophilus influenzae type B
- B. Varicella
- C. Hepatitis B
- D. Diphtheria
Correct Answer: B
Rationale: The correct answer is B: Varicella. At the age of 5, children are due for their second dose of the Varicella vaccine according to the current immunization schedule. Varicella vaccine is given to protect against chickenpox. Haemophilus influenzae type B and Hepatitis B vaccines are typically administered at earlier ages. Diphtheria vaccine is usually given in combination with other vaccines and not as a standalone. In summary, Varicella is the correct choice as it aligns with the child's age and the recommended immunization schedule, while the other options are not due at this time.