Nokea
A nurse is caring for a 1-year-old child who has been hospitalized. Which of the following items in the child's room is a common source of health care-associated infections?
- A. Disposable diapers
- B. Bedside commode
- C. Protective plastic gowns
- D. Unopened bottles of formula
Correct Answer: B
Rationale: The correct answer is B: Bedside commode. This item can harbor bacteria and pathogens if not properly cleaned and sanitized, leading to healthcare-associated infections. Disposable diapers (A) are single-use and unlikely to cause infections. Protective plastic gowns (C) are meant to prevent infections. Unopened bottles of formula (D) are sterile and not a common source of infections.
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A nurse is assessing a child who has bacterial pneumonia. Which of the following manifestations should the nurse expect?
- A. Steatorrhea
- B. Fever
- C. Drooling
- D. Tinnitus
Correct Answer: B
Rationale: The correct answer is B: Fever. In bacterial pneumonia, the body's immune response leads to fever as a common manifestation due to the infection. This is because the body is trying to fight off the bacterial invasion. Steatorrhea (A) is not typically associated with bacterial pneumonia. Drooling (C) is more commonly seen in conditions affecting the mouth or throat. Tinnitus (D) is a symptom related to the ears and is not typically associated with pneumonia. Therefore, the presence of fever is the most relevant sign in a child with bacterial pneumonia.
A nurse in the emergency department is caring for a 10-year-old child. The nurse is assessing the child. Which of the following findings require follow-up? Select the 5 findings that require follow-up.
- A. Temperature
- B. Heart rate
- C. Report of pain
- D. Respiratory rate
- E. Tonsillar findings
- F. Oxygen saturation
Correct Answer: A,B,C,D,E,F
Rationale: The correct answer includes all options (A, B, C, D, E, F) because they are essential vital signs and key indicators of the child's health status. Temperature (A), heart rate (B), respiratory rate (D), and oxygen saturation (F) are crucial physiological parameters that can indicate underlying health issues if abnormal. Report of pain (C) is important to assess the child's comfort and potential underlying conditions. Tonsillar findings (E) could indicate infections or other throat issues. Follow-up on all these findings is necessary for a comprehensive assessment of the child's health.
A nurse is assessing a school-age child who is receiving morphine. For which of the following adverse effects should the nurse monitor?
- A. Hypertension
- B. Bradypnea
- C. Stevens-Johnson syndrome
- D. Prolonged wound healing
Correct Answer: B
Rationale: The correct answer is B: Bradypnea. Morphine is an opioid that can cause respiratory depression, leading to bradypnea (slow breathing). The nurse should monitor the child's respiratory rate regularly as a safety precaution. Hypertension (A), Stevens-Johnson syndrome (C), and prolonged wound healing (D) are not typically associated with morphine use in school-age children. Monitoring for these adverse effects would not be a priority in this situation.
A nurse is providing teaching to a parent of a child who has HIV. Which of the following statements by the parent indicates an understanding of the teaching?
- A. The risk of transmission decreases once my child is on zidovudine for 2 weeks
- B. My child will need to double his medications for the next 6 months.
- C. My child will need to repeat his childhood immunizations once he's in remission.
- D. I will ensure that my child is tested for tuberculosis every year.
Correct Answer: D
Rationale: The correct answer is D because regular testing for tuberculosis is crucial for individuals with HIV due to their increased risk of developing tuberculosis. This indicates the parent understands the importance of monitoring for potential complications. Choice A is incorrect because zidovudine does not impact transmission risk. Choice B is incorrect as doubling medications without healthcare provider guidance can be harmful. Choice C is incorrect as childhood immunizations are typically not repeated in remission.
A nurse is assessing the fontanels of an infant. Which of the following findings should the nurse recognize as an expected finding?
- A. The posterior fontanel is open.
- B. The anterior fontanel is open.
- C. Both fontanels are the same size.
- D. Both fontanels show molars.
Correct Answer: B
Rationale: The correct answer is B: The anterior fontanel is open. The anterior fontanel is typically open in infants to allow for brain growth and development. It is a normal finding during infancy and should close by around 18 months of age. Choice A is incorrect because the posterior fontanel closes shortly after birth. Choice C is incorrect because the fontanels are not expected to be the same size; the anterior fontanel is larger than the posterior fontanel. Choice D is incorrect because the presence of molars in the fontanels would not be expected and could indicate a medical issue.