Nokea
A 6-year-old boy with bronchial asthma takes the beta-adrenergic agonist agent albuterol. The child's mother tells the nurse that she uses this medication to open his son's airway when he is having trouble breathing. What is the nurse's best response?
- A. Advise the mother that overuse of the drug may cause chronic bronchitis.
- B. Assure the mother that she is using the medication correctly.
- C. Confirm that the medication helps to reduce airway inflammation.
- D. Recommend that the mother bring the child in for immediate evaluation.
Correct Answer: B
Rationale: Using albuterol to relieve acute breathing difficulties is correct, as it relaxes airway muscles.
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The nurse is caring for a school-age child with crusting and swollen eyelids, purulent drainage, and inflamed conjunctiva. The child receives a prescription for an ophthalmic anti-infective ointment. Which instruction should the nurse provide the child's caregivers during discharge education?
- A. Discontinue the ointment once drainage resolves.
- B. Prepare the child for blurry vision after ointment application.
- C. Use a disposable moist wipe to remove eye crusts.
- D. Remove secretions by wiping toward the opposite eye.
Correct Answer: B
Rationale: Ophthalmic ointment can cause temporary blurry vision, and preparing the child for this effect is important.
The nurse is monitoring a child with hydrocephalus who received a repeat ventriculoperitoneal (VP) shunt yesterday. Which assessment finding indicates to the nurse that the shunt is functioning normally?
- A. The child has grown in height since the previous shunt placement.
- B. The child is afebrile with normal vital signs postoperatively.
- C. An intracranial pressure (ICP) monitoring probe is in place.
- D. The child reports no evidence of continuous headaches.
Correct Answer: D
Rationale: The absence of continuous headaches indicates the VP shunt is functioning normally by relieving pressure on the brain, a primary symptom of hydrocephalus.
The nurse is preparing to administer medications for an eight-month-old infant with heart failure. The infant has a blood pressure of 114/66 mm Hg, apical pulse of 88 beats/minute, and respirations of 30 breaths/minute. Which medication should the nurse withhold until the healthcare provider is notified?
- A. Digoxin.
- B. Furosemide.
- C. Hydralazine.
- D. Enalapril.
Correct Answer: A
Rationale: Digoxin should be withheld if the apical pulse is below 90 beats/minute in infants, as it may indicate toxicity.
A mother brings her 2-month-old to the well-baby clinic. She states that when she kisses her baby, the infant's skin tastes salty. The nurse should prepare the mother for what standard diagnostic test to screen for cystic fibrosis (CF)?
- A. Sweat-chloride test.
- B. Faecal-fat test.
- C. Pulmonary-function test.
- D. Potassium chloride test.
Correct Answer: A
Rationale: Salty-tasting skin is a hallmark of cystic fibrosis, and the sweat-chloride test is the standard diagnostic test.
The nurse is caring for a toddler with autism spectrum disorder and failure to thrive. Which intervention should the nurse implement?
- A. Provide structured meal times.
- B. Offer food even if disinterested.
- C. Incorporate play during meals.
- D. Allow multiple food choices.
Correct Answer: A
Rationale: Structured meal times promote routine and reduce sensory overload, aiding feeding in children with autism spectrum disorder.