Nokea
A 12-year-old with cystic fibrosis is being treated in the hospital for pneumonia. The physician is calling in a telephone order for ampicillin. The nurse should do which of the following? Select all that apply.
- A. Ask the unit clerk to listen on the speaker phone with the nurse and write down the order.
- B. Ask the physician to come to the hospital and write the order.
- C. Repeat the order to the physician.
- D. Ask the physician to confirm that the order is correct as understood by the nurse.
- E. Ask the nursing supervisor to cosign the telephone order as transcribed by the nurse.
Correct Answer: C,D
Rationale: Repeating the order to the physician and asking for confirmation ensures accuracy and safety in transcribing the telephone order for ampicillin.
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Assessment of a school-age child with Guillain-Barré syndrome reveals absent gag and cough reflexes. Which of the following nursing diagnoses should receive the highest priority during the acute phase?
- A. Risk for infection due to altered immune system.
- B. Ineffective breathing pattern related to neuromuscular impairment.
- C. Impaired swallowing related to neuromuscular impairment.
- D. Total urinary incontinence related to fluid losses.
Correct Answer: B
Rationale: Absent gag and cough reflexes increase the risk of respiratory compromise, making ineffective breathing pattern the highest priority.
A nurse is teaching an 8-year-old with diabetes and her parents about managing diabetes during illness. The nurse determines the parents understand the instruction when they indicate that, when the child is ill, they will provide:
- A. More calories.
- B. More insulin.
- C. Less insulin.
- D. Less protein and fat.
Correct Answer: B
Rationale: Illness increases insulin resistance, often requiring more insulin to manage elevated blood glucose. Calorie, protein, or fat adjustments are secondary to insulin needs.
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 nurse is assessing an infant with failure to thrive. Which finding requires immediate intervention?
- A. Weight below 5th percentile.
- B. Heart rate of 180 bpm.
- C. Poor feeding for 1 week.
- D. Dry mucous membranes.
Correct Answer: B
Rationale: A heart rate of 180 bpm suggests distress (e.g., dehydration, sepsis), requiring urgent evaluation. Low weight, poor feeding, and dry membranes are concerning but less acute.
Which of the following should the nurse expect to observe in an infant with intussusception before surgical intervention?
- A. Fever and lethargy.
- B. Currant jelly stools.
- C. Frequent loose stools.
- D. Increased appetite.
Correct Answer: B
Rationale: Currant jelly stools are a classic sign of intussusception due to mucosal bleeding.