Nokea
A 15-year-old has been diagnosed with acute glomerulonephritis and has been in the hospital for 1 day. Which of the following findings requires immediate action?
- A. Large amount of generalized edema.
- B. Urine specific gravity of 1.030.
- C. Large amount of albumin in the urine.
- D. 24-hour output of 1,500 mL.
Correct Answer: A
Rationale: Severe edema could indicate worsening condition.
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A nurse compares a child's height and weight with standard growth charts and finds the child to be in the 50th percentile for height and in the 45th percentile for weight. The nurse interprets these findings as indicating that the child is:
- A. Average height and weight.
- B. Overweight for height.
- C. Underweight for height.
- D. Abnormal in height.
Correct Answer: A
Rationale: 50th percentile height and 45th percentile weight indicate average growth, as they are close.
After teaching the parent of an infant who has had a surgical repair for a cleft lip about the use of elbow restraints at home, the nurse determines that the teaching has been successful when the parent states which of the following?
- A. We will keep the restraints on continuously except when checking the skin under them for redness.
- B. We will keep the restraints on during the day while he is awake, but take them off when we put him to bed at night.
- C. After we get home, we won't have to use the restraints because our child does not suck on his thumb.
- D. We will be sure to keep the restraints on all the time until we come to see the physician for a follow-up visit.
Correct Answer: A
Rationale: Elbow restraints should be worn continuously but removed periodically to check for skin irritation, ensuring both safety and comfort.
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.
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.
Which of the following would be most appropriate to institute when a school-age child with burns becomes angry and combative when it is time to change the dressings and apply mafenide acetate (Sulfamylon)?
- A. Ensure parental support during the dressing.
- B. Allow the child to assist in removing the dressings and applying the cream.
- C. Give the child permission to cry during the procedure.
- D. Allow the child to schedule the time for dressing changes.
Correct Answer: B
Rationale: Allowing the child to participate fosters a sense of control, reducing fear and combative behavior. Parental support and crying are helpful but less empowering, and scheduling may disrupt care.