Nokea
A 4-year-old hospitalized with failure to thrive (FTT) has orders for daily weights, strict I&O, and calorie counts. Which action by the nurse is a concern?
- A. Weighing the child every morning after breakfast.
- B. Weighing the child with only undergarments on.
- C. Sitting with the child while she eats her meals.
- D. Weighing the child after she has been fed.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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Extraneural metastasis from primary brain tumors is MOST commonly likely to occur in which tumor?
- A. medulloblastoma
- B. primitive neuroectodermal tumor (PNET)
- C. ependymoma
- D. malignant glioma
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
In caring for an adolescent with severe abdominal pain due to appendicitis, where should the nurse identify as McBurney's point?
- A. Right lower quadrant
- B. Left lower quadrant
- C. Right upper quadrant
- D. Left upper quadrant
Correct Answer: A
Rationale: McBurney's point is located in the right lower quadrant of the abdomen, specifically between the umbilicus and the anterior iliac crest. This point is significant in diagnosing appendicitis, as tenderness at McBurney's point is a classic sign of appendicitis and indicates inflammation near the appendix.
Which of the following is NOT an appropriate method to decrease the incidence of PONV?
- A. Preoperative fasting
- B. Hydration using ketorolac
- C. Glucose supplementation
- D. Prophylactic use of ondansetron
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A nurse is auscultating the lungs of an adolescent who has asthma. The nurse should identify the sound as which of the following?
- A. Biots respiration
- B. Chaney Stokes respiration
- C. tachypnea
- D. Bradypnea
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
During a home care visit for an infant diagnosed with gastroesophageal reflux, which parental action observed requires intervention by the nurse?
- A. The infant's formula is mixed with rice cereal.
- B. The mother positions the infant in a high Fowler position while feeding.
- C. After feeding, the infant is placed in a car seat.
- D. The mother administers ranitidine (Zantac) to the infant using a syringe.
Correct Answer: C
Rationale: Placing an infant diagnosed with gastroesophageal reflux in a car seat after feeding can increase the risk of reflux and aspiration. The semi-upright or high Fowler position is recommended to help reduce reflux symptoms during feeding. Adding rice cereal to formula can help thicken it and reduce reflux episodes. Administering ranitidine using a syringe is a common method of oral medication administration.