Nokea
A 2-year-old boy with short bowel syndrome has progressed to receiving enteral feedings only. Today his stools are occurring more frequently and have a more liquid consistency. His temperature is 102.2°F and he has vomited twice in the past four hours. Which assessment finding indicates that the child is becoming dehydrated?
- A. Occult blood in the stool
- B. Abdominal distention
- C. Elevated urine specific gravity
- D. Hyperactive bowel sounds
Correct Answer: C
Rationale: Step 1: Elevated urine specific gravity indicates increased concentration of urine, a sign of dehydration.
Step 2: In dehydration, the body conserves water, leading to concentrated urine.
Step 3: The child's symptoms (increased stools, liquid consistency, fever, vomiting) suggest dehydration.
Step 4: Other choices (A: occult blood, B: distention, D: hyperactive bowel sounds) are not specific to dehydration.
Summary: Elevated urine specific gravity is key as it directly reflects dehydration, unlike the other choices which are not specific indicators of dehydration.
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A 3-year-old boy is brought to the emergency center with dysphagia, drooling, a fever of 102°F, and stridor. Which intervention should the nurse implement first?
- A. Place the child in a mist tent
- B. Obtain a sputum culture
- C. Prepare for an emergent tracheostomy
- D. Examine the child's oropharynx and report the findings to the healthcare provider
Correct Answer: A
Rationale: The correct answer is A: Place the child in a mist tent. This intervention is crucial in managing a child with croup, which presents with stridor, fever, and respiratory distress. Placing the child in a mist tent provides humidified air, which can help reduce airway inflammation and ease breathing. It is the first-line treatment for croup and should be initiated promptly to relieve the child's symptoms. Obtaining a sputum culture (B) is not necessary in this scenario as the child's presentation is consistent with croup, which is a clinical diagnosis. Preparing for an emergent tracheostomy (C) is an invasive procedure that should only be considered if other treatments fail. Examining the child's oropharynx (D) can be helpful but is not the most urgent intervention in this situation.
A client who has a flaccid bladder is placed on a bladder training program. Which instruction should the nurse include in this client's teaching plan?
- A. Use manual pressure to express urine
- B. Perform the Crede maneuver
- C. Apply an external urinary drainage device
- D. Take a warm sitz bath twice a day
Correct Answer: B
Rationale: The correct answer is B: Perform the Crede maneuver. This is the appropriate instruction for a client with a flaccid bladder on a bladder training program. The Crede maneuver involves applying manual pressure on the bladder to assist with urine elimination. This technique helps to promote bladder emptying and prevent urinary retention.
A: Using manual pressure to express urine is not recommended as it can lead to urinary tract infections and damage to the bladder.
C: Applying an external urinary drainage device is not part of bladder training and does not address the issue of bladder emptying.
D: Taking a warm sitz bath twice a day does not directly address the client's flaccid bladder and is not a component of bladder training.
A 9-year-old received a short arm cast for a right radius. To relieve itching under the child's cast, which instructions should the nurse provide to the parents?
- A. Blow cool air from a hair dryer under the cast
- B. Twist the cast back and forth
- C. Shake powder into the cast
- D. Push a pencil under the cast edge
Correct Answer: A
Rationale: The correct answer is A: Blow cool air from a hair dryer under the cast. This method helps to relieve itching by providing airflow without causing damage to the cast or skin. It is safe and effective.
Choice B: Twisting the cast back and forth may cause discomfort or injury to the child's arm.
Choice C: Shaking powder into the cast can create a mess and may lead to skin irritation or infection.
Choice D: Pushing a pencil under the cast edge can cause damage to the skin or lead to complications.
When caring for a laboring client whose contractions are occurring every 2-3 minutes, the nurse should document that the pump is infusing how many ml/hour?
- A. 5
- B. 10
- C. 15
- D. 20
Correct Answer: A
Rationale: The correct answer is A: 5 ml/hour. To calculate the infusion rate, you need to divide the total amount infused by the total time in hours. Given contractions every 2-3 minutes, which is equivalent to 20-30 contractions per hour, the pump should infuse at 5 ml/hour to ensure proper medication delivery. Choices B, C, and D are incorrect because they do not correspond to the frequency of contractions and may lead to under or overmedication.
A client with an electrical burn on the forearm asks the nurse why there is no feeling of pain from the burn. During the dressing change, the nurse determines that the burn is dry, waxy, and white. What information should the nurse provide this client?
- A. The depth of tissue destruction is minor
- B. Pain is interrupted due to nerve compression
- C. The full thickness burn has destroyed the nerves
- D. Second-degree burns are not usually painful
Correct Answer: C
Rationale: The correct answer is C because full-thickness burns destroy nerve endings, resulting in the absence of pain sensation. The dry, waxy, and white appearance indicates tissue destruction extending through the epidermis and dermis. Choices A and D are incorrect because dry, waxy, and white appearance signifies a deeper burn, not a minor or superficial burn, and second-degree burns typically involve pain sensation. Choice B is incorrect as nerve compression does not explain the lack of pain sensation in a full-thickness burn.