Nokea
A 3-year-old child is admitted to the hospital with severe dehydration. The healthcare provider prescribes an IV infusion of 0.9% normal saline. The nurse notes that the child's heart rate is 150 beats per minute, and the blood pressure is 90/50 mm Hg. What should the nurse do first?
- A. Administer the IV fluids as prescribed
- B. Notify the healthcare provider
- C. Check the child's urine output
- D. Reassess the child's vital signs in 30 minutes
Correct Answer: A
Rationale: In a pediatric patient with severe dehydration and signs of compromised hemodynamics such as tachycardia (heart rate of 150 bpm) and hypotension (blood pressure of 90/50 mm Hg), the priority intervention is to administer IV fluids as prescribed. Immediate fluid resuscitation is essential to restore hydration, improve perfusion, and stabilize the child's vital signs. While it's important to monitor urine output, initiating fluid resuscitation takes precedence in this situation. Notifying the healthcare provider can cause a delay in critical intervention, and waiting to reassess vital signs in 30 minutes can be detrimental in a child with severe dehydration and compromised hemodynamics.
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The practical nurse is providing care for a toddler who has just returned from surgery for a tonsillectomy. Which intervention is a priority in the immediate postoperative period?
- A. Offer clear fluids frequently.
- B. Encourage the child to cough and deep breathe.
- C. Monitor for frequent swallowing.
- D. Apply a warm compress to the throat area.
Correct Answer: C
Rationale: Monitoring for frequent swallowing is a priority intervention in the immediate postoperative period after a tonsillectomy. Frequent swallowing may indicate bleeding from the surgical site, which requires immediate attention to prevent complications such as hemorrhage. Offering clear fluids frequently may not be appropriate immediately after surgery. Encouraging coughing and deep breathing may increase the risk of bleeding. Applying a warm compress to the throat area is not recommended as it can increase blood flow to the surgical site, potentially causing bleeding.
What information should be reinforced with the mother of a child with ringworm (Tinea)?
- A. Ringworm is not contagious.
- B. Tinea infections are indicative of poor hygiene and uncleanliness.
- C. Tinea infections are spread by direct and indirect contact.
- D. Ringworm often subsides spontaneously.
Correct Answer: C
Rationale: The correct answer is C. Ringworm, a fungal infection, is highly contagious and can be spread by direct contact with infected individuals or animals and indirectly through contaminated objects. It is important for the mother to understand the modes of transmission to prevent the spread of the infection to others and to take necessary precautions to ensure proper treatment and containment of the condition. Choices A and D are incorrect because ringworm is indeed contagious, and it may not always subside spontaneously. Choice B is misleading as tinea infections are not solely indicative of poor hygiene; they can affect anyone, regardless of personal cleanliness.
The parents of a 2-month-old infant, who is being discharged after treatment for pyloric stenosis, are being educated by the healthcare provider. Which statement by the parents indicates a need for further teaching?
- A. We should feed our baby in an upright position
- B. We should avoid feeding our baby solid foods until at least 6 months of age
- C. We will lay our baby on their stomach to sleep
- D. We will burp our baby frequently during feedings
Correct Answer: C
Rationale: The correct answer is C. Placing babies on their stomach to sleep increases the risk of sudden infant death syndrome (SIDS). The safest sleep position for infants is on their back to reduce the risk of SIDS. Teaching parents about safe sleep practices is crucial in preventing potential harm to the infant. Choices A, B, and D are all correct statements that promote the well-being of the infant. Feeding the baby in an upright position helps prevent reflux, delaying solid foods until 6 months of age is recommended for proper growth and development, and burping the baby frequently during feedings helps prevent gas buildup and colic.
What response should the practical nurse (PN) provide when a school-age child asks to talk with a dying sister?
- A. Talk loudly to ensure the dying person hears and recognizes others' voices.
- B. Touch can provide a tactile presence if the dying person does not respond to words.
- C. Sitting close offers the dying person the sensation of others' presence.
- D. Although the dying person may not respond, they can still hear what is said.
Correct Answer: D
Rationale: The correct response is D because it is believed that hearing is the last sense to go. Even if the dying person does not respond, speaking to them can still provide comfort. Choice A is incorrect because talking loudly is not necessary and can be distressing. Choice B is incorrect as it focuses on touch rather than the sense of hearing. Choice C is incorrect because sitting close may not necessarily help the dying person hear better.
When caring for a child experiencing severe asthma symptoms, which medication should the practical nurse anticipate being administered first?
- A. Inhaled corticosteroids.
- B. Oral corticosteroids.
- C. Short-acting beta agonists.
- D. Leukotriene receptor antagonists.
Correct Answer: C
Rationale: In the management of acute asthma exacerbations, the first-line medication for quick relief of bronchoconstriction is a short-acting beta agonist, such as albuterol. These medications help to rapidly open up the airways, providing immediate relief to the patient. Inhaled corticosteroids are more commonly used for long-term control of asthma symptoms, while oral corticosteroids and leukotriene receptor antagonists are often reserved for more severe or chronic cases. Therefore, in a child experiencing severe asthma symptoms, the practical nurse should anticipate the administration of short-acting beta agonists as the initial intervention to provide quick relief and improve breathing.