Nokea
A 14-year-old adolescent is hospitalized with cystic fibrosis. What nursing note entry represents best documentation of his breakfast meal?
- A. Tolerated breakfast well
- B. Finished all of breakfast ordered
- C. One pancake, eggs, and 240 ml OJ
- D. No documentation is needed for this age child.
Correct Answer: C
Rationale: Documenting specific intake, like one pancake, eggs, and 240 ml orange juice, provides essential data for assessing caloric needs and eating patterns, critical for cystic fibrosis management. General statements like ?tolerated well? or ?finished all? lack detail, and documentation is always needed.
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A nurse must do a venipuncture on a 6-year-old child. What consideration is important in providing atraumatic care?
- A. Use an 18-gauge needle if possible.
- B. Show the child the equipment to be used before the procedure.
- C. If not successful after four attempts, have another nurse try.
- D. Restrain the child completely.
Correct Answer: B
Rationale: Showing the child the equipment before the procedure reduces fear and supports atraumatic care. An 18-gauge needle is too large, a two-try policy (four attempts total) is preferred, and full restraint is unnecessary, favoring therapeutic hugging instead.
A critically ill child has hyperthermia. The parents ask the nurse to give an antipyretic such as acetaminophen. How should the nurse respond to the parents?
- A. Febrile seizures can result.
- B. Antipyretics may cause malignant hyperthermia.
- C. Antipyretics are of no value in treating hyperthermia.
- D. Liver damage may occur in critically ill children.
Correct Answer: C
Rationale: Antipyretics are ineffective for hyperthermia, as the body?s temperature set point is normal, requiring cooling measures instead. Seizures are linked to fever, not hyperthermia; malignant hyperthermia is unrelated to antipyretics; and while liver damage is a risk with acetaminophen, it?s not the primary reason.
A toddler is being sent to the operating room for surgery at 9 AM. As the nurse prepares the child, what is the priority intervention?
- A. Administering preoperative antibiotic
- B. Verifying that the child and procedure are correct
- C. Ensuring that the toddler has been NPO since midnight
- D. Informing the parents where they can wait during the procedure
Correct Answer: B
Rationale: Verifying the correct child and procedure is the priority to ensure safety and prevent errors. Administering antibiotics is secondary, clear liquids can be given up to 2 hours before surgery, and informing parents about waiting areas is important but not the priority.
A bone marrow biopsy will be performed on a 7-year-old girl. She wants her mother to hold her during the procedure. How should the nurse respond?
- A. Holding your child is unsafe.
- B. Holding may help your child relax.
- C. Hospital policy prohibits this interaction.
- D. Holding your child is unnecessary given the childs age.
Correct Answer: B
Rationale: Allowing the mother to hold the child, after assessing safety and familiarity with the procedure, can help the child relax, respecting her preference. Claiming it?s unsafe or against policy is incorrect if family-centered care is supported, and dismissing the need ignores the child?s comfort.
A 5-year-old child returns from the pediatric intensive care unit after abdominal surgery. The orders state to monitor vital signs every 2 hours. On assessment, the nurse observes that the childs heart rate is 20 beats/min less than it was preoperatively. What should be the nurses next action?
- A. Follow the orders and check in 2 hours.
- B. Ask the parents if this is the childs usual heart rate.
- C. Recheck the pulse and blood pressure in 15 minutes.
- D. Notify the surgeon that the child is probably going into shock.
Correct Answer: C
Rationale: A 20 beats/min decrease in heart rate is significant and warrants rechecking pulse and blood pressure in 15 minutes to assess stability. Waiting 2 hours delays intervention, parents may not know the usual rate, and assuming shock without further data is premature.