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A 2-year-old child with heart failure (HF) is admitted for replacement of a graft for coarctation of the aorta. Prior to administering the next dose of digoxin (Lanoxin), the nurse obtains an apical heart rate of 128 bpm. What action should the nurse take?
- A. Determine the pulse deficit.
- B. Administer the scheduled dose.
- C. Calculate the safe dose range.
- D. Review the serum digoxin level.
Correct Answer: B
Rationale: Administering the scheduled dose is appropriate in this scenario since the heart rate of 128 bpm is within an acceptable range for a 2-year-old child with heart failure. Monitoring for signs of digoxin toxicity is important; however, the immediate action required is to administer the scheduled dose as prescribed based on the heart rate assessment.
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Which nursing intervention is most important to assist in detecting hypopituitarism and hyperpituitarism in children?
- A. Carefully recording the height and weight of children to detect inappropriate growth.
- B. Performing head circumference measurements on infants under one year of age.
- C. Assessing for behavioral problems at home and school by interviewing the parents.
- D. Noting tracked weight gain without a gain in height on a growth chart.
Correct Answer: A
Rationale: Recording the height and weight of children is crucial in detecting growth abnormalities like hypopituitarism and hyperpituitarism. Inappropriate growth patterns, such as disproportionate weight gain or stunted height, can be indicative of these conditions. Regular monitoring of height and weight is a fundamental nursing intervention that can aid in the early identification and management of pituitary-related disorders in children.
A 6 year old who has asthma is demonstrating a prolonged expiratory phase and wheezing and has a 35% of personal best peak expiratory flow rate (PEFR). Based on these findings, what actions should the nurse take first?
- A. Administer a prescribed bronchodilator.
- B. Encourage the child to cough and deep breath.
- C. Report findings to the health care provider.
- D. Determine what triggers precipitated this attack.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
When instilling ear drops in a 2-year-old child, how should the practical nurse (PN) position the earlobe to straighten the external auditory canal?
- A. Up and back.
- B. Down and back.
- C. Up and forward.
- D. Down and forward.
Correct Answer: B
Rationale: When administering ear drops to a child under three years old, it is essential to pull the earlobe down and back. This positioning helps straighten the external auditory canal, facilitating the proper administration of the ear drops. Pulling the earlobe down and back in young children aims to ensure that the medication reaches the intended area for optimal effectiveness.
The parents of a 10-year-old child with newly diagnosed type 1 diabetes are being taught by the nurse about managing their child's condition. Which statement by the parents indicates they need further teaching?
- A. We should rotate injection sites to prevent tissue damage
- B. Our child should avoid all sugary foods and drinks
- C. We will monitor blood glucose levels regularly
- D. Our child needs to wear a medical alert bracelet
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
When developing a behavior modification program for an extremely aggressive 10-year-old boy, what should the nurse do first?
- A. Identify what activities, foods, and toys the child enjoys
- B. Assess the child's previous reactions to punishment
- C. Offer the child positive feedback
- D. Involve other children on the unit in describing the token system
Correct Answer: A
Rationale: The first step in developing a behavior modification program for an extremely aggressive 10-year-old boy is to identify what activities, foods, and toys the child enjoys. Understanding the child's motivations is crucial in creating an effective behavior modification plan tailored to his interests and preferences, which can help in positively reinforcing desired behaviors.