Nokea
A 12-year-old client with asthma is receiving I.V. hydrocortisone, ampicillin, and theophylline. The client vomits after breakfast and lunch, is very irritable, and has a heart rate of 120 beats/minute. The nurse should:
- A. Offer small amounts of clear liquids.
- B. Inform the primary health care provider that the child is having an allergic reaction to the ampicillin.
- C. Add the missed dose of theophylline and inform the primary health care provider of the vomiting.
- D. Administer oxygen to decrease the heart rate.
Correct Answer: C
Rationale: Vomiting, irritability, and tachycardia (heart rate of 120 bpm) are signs of theophylline toxicity. The nurse should withhold further doses, inform the provider of the vomiting, and monitor for toxicity, as additional theophylline could worsen symptoms.
You may also like to solve these questions
When teaching the family of an older infant who has had a hip spica cast applied for developmental dysplasia of the hip, which information should the nurse include when describing the abduction stabilizer bar?
- A. It can be adjusted to a position of comfort.
- B. It is used to lift the child.
- C. It adds strength to the cast.
- D. It is necessary to turn the child.
Correct Answer: C
Rationale: The abduction stabilizer bar maintains the legs in abduction to promote hip joint stability and adds structural strength to the cast.
A toddler diagnosed with nephrotic syndrome has a nursing diagnosis of Excess fluid volume related to fluid accumulation in the tissues. Which measure should the nurse anticipate including in the child's plan of care?
- A. Limiting visitors to 2 to 3 hours a day.
- B. Maintaining strict bed rest.
- C. Testing urine specific gravity every shift.
- D. Weighing the child before breakfast.
Correct Answer: D
Rationale: Daily weights monitor fluid balance.
A preschooler with pneumococcal meningitis is receiving intravenous antibiotic therapy. When discontinuing the intravenous therapy, the nurse allows the child to apply a dressing to the area where the needle is removed. The nurse's rationale for doing so is based on the interpretation that a child in this age-group has a need to accomplish which of the following?
- A. Trust those caring for her.
- B. Find diversional activities.
- C. Protect the image of an intact body.
- D. Relieve the anxiety of separation from home.
Correct Answer: C
Rationale: Allowing the child to apply a dressing supports their developmental need to maintain body integrity, reducing anxiety about medical procedures.
The physician orders intravenous fluid replacement therapy with potassium chloride to be added for a child with severe gastroenteritis. Before adding the potassium chloride to the intravenous fluid, which of the following assessments would be most important?
- A. Ability to void.
- B. Passage of stool today.
- C. Baseline electrocardiogram.
- D. Serum calcium level.
Correct Answer: A
Rationale: Ensuring the ability to void confirms renal function before administering potassium.
After teaching the parents about the cause of ringworm of the scalp (tinea capitis), which of the following, if stated by the father, indicates successful teaching?
- A. It results from overexposure to the sun.
- B. It's caused by infestation with a mite.
- C. It's a fungal infection of the scalp.
- D. It's an allergic reaction.
Correct Answer: C
Rationale: Tinea capitis is caused by a fungal infection, not mites, sun exposure, or allergies.