Nokea
If the nurse documents all the following data, which finding should be reported immediately?
- A. Refusal to eat
- B. Complaint of nausea
- C. Absent bowel sounds
- D. Temperature of 101°F (38.3°C) orally
Correct Answer: C
Rationale: Absent bowel sounds may indicate peritonitis or bowel obstruction, serious complications of appendicitis requiring immediate reporting to prevent further deterioration.
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Which nursing interventions are essential to restore the child's fluid and electrolyte balance during the emergent phase of burn care and treatment? Select all that apply.
- A. Initiate the administration of I.V. fluids.
- B. Track the child's vital signs.
- C. Give the child sips of water.
- D. Encourage the child to consume protein-rich feedings.
- E. Monitor the child's urine output.
- F. Assemble equipment for a small-gauge venous catheter.
Correct Answer: A,B,E,F
Rationale: During the emergent phase, I.V. fluids restore fluid and electrolyte balance due to massive losses. Monitoring vital signs and urine output assesses fluid status, and preparing venous access ensures timely administration. Oral fluids and protein-rich feedings are inappropriate due to gastrointestinal dysfunction.
The nurse is caring for the newborn infant. The nurse should prepare to assess the newborn’s anterior fontanel by which method?
- A. Lay the infant on his or her back.
- B. Stimulate the infant to cry strongly.
- C. Feel near the parietal and occipital bones.
- D. Place the infant in a sitting position.
Correct Answer: D
Rationale: The anterior fontanel is assessed with the infant in a sitting position (45°–90°) to evaluate size and abnormalities. Supine positioning or crying may cause bulging and parietal/occipital bones locate the posterior fontanel.
Which nursing interventions should be included in the care plan of a child in skeletal traction? Select all that apply.
- A. Maintain the child in the prone position.
- B. Clean the pin site every 8 hours.
- C. Release weights on the traction every 2 hours.
- D. Monitor client for signs of cloudy urine.
- E. Cover protruding tips of pins with protective materials.
Correct Answer: B,D,E
Rationale: Cleaning pin sites every 8 hours prevents infection, monitoring for cloudy urine detects urinary tract infections due to immobility, and covering pin tips ensures safety. Prone position is not standard, and weights should not be released.
Which symptom reported by the parents is best indicative of methamphetamine abuse by the adolescent?
- A. Watery eyes
- B. Drowsiness
- C. Excessive nasal drainage
- D. Marked nervousness
Correct Answer: D
Rationale: Methamphetamine, a stimulant, causes marked nervousness due to increased central nervous system activity, making it a key indicator of abuse.
The nurse is caring for a preterm infant who must be fed via bolus gavage feeding. The infant has a 5 French feeding tube already secured in the left naris. The nurse has aspirated the infant’s stomach contents, noting color, amount, and consistency, and has reinserted the residual amount because it was less than one-fourth the previous feeding. Prioritize the remaining steps that the nurse should take to complete this feeding.
- A. Elevate the syringe 6 to 8 inches over the infant’s head.
- B. Position the infant on the right side.
- C. Uncrimp the tubing and allow the feeding to flow by gravity at a slow rate.
- D. Crimp the feeding tube and pour the specified amount of formula or breast milk into the barrel.
- E. Cap the lavage feeding tube.
Correct Answer: D, A, F, C, E, B, G
Rationale: Sequence: Position infant on right side (D) to reduce aspiration risk connect syringe barrel (A) crimp tube and pour formula (F) elevate syringe (C) uncrimp for gravity flow (E) clear tubing with air (B) cap tube (G).