Nokea
A 6-year-old child needs to drink 1 L of GoLYTELY in preparation for a computed tomography scan of the abdomen. To encourage the child to drink, what should the nurse do?
- A. Give him a large cup with ice so it tastes better.
- B. Restrict him to his room until he drinks the GoLYTELY.
- C. Use little cups and make a game to reward him for each cup he drinks.
- D. Tell him that if he does not finish drinking by a set time, the practitioner will be angry.
Correct Answer: C
Rationale: Using small cups and making a game with rewards makes the large volume of GoLYTELY less daunting and encourages compliance. A large cup with ice increases the volume, restriction is punitive, and threats about the practitioner are ineffective and inappropriate.
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An 11-month-old hospitalized boy is restrained because he is receiving intravenous (IV) fluids. His grandmother has come to stay with him for the afternoon and asks the nurse if the restraints can be removed. What nurses response is best?
- A. Restraints need to be kept on all the time.
- B. That is fine as long as you are with him.
- C. That is fine if we have his parents consent.
- D. The restraints can be off only when the nursing staff is present.
Correct Answer: B
Rationale: Removing restraints when a responsible adult, like the grandmother, is present to supervise protects the IV site while promoting comfort. Keeping restraints on constantly, requiring parental consent, or limiting removal to staff presence is overly restrictive.
A 16-year-old girl comes to the pediatric clinic for information on birth control. The nurse knows that before this young woman can be examined, consent must be obtained from which source?
- A. Herself
- B. Her mother
- C. Court order
- D. Legal guardian
Correct Answer: A
Rationale: Contraceptive advice is considered a medically emancipated condition, allowing the 16-year-old to provide her own informed consent. Parental or guardian consent is not required, and a court order is unnecessary for this routine care.
A 6-year-old boy is hospitalized for intravenous antibiotic therapy. He eats very little on his regular diet trays. He tells the nurse that all he wants to eat is pizza, tacos, and ice cream. What nursing action is the most appropriate?
- A. Request these favorite foods for him.
- B. Identify healthier food choices that he likes.
- C. Explain that he needs fruits and vegetables.
- D. Reward him with ice cream at the end of every meal that he eats.
Correct Answer: A
Rationale: Requesting the child?s favorite foods encourages nutritional intake during illness, which can be supplemented with healthier options. Explaining nutritional needs or rewarding with ice cream is less effective, and focusing only on healthier foods may discourage eating.
A 4-year-old girl is admitted to outpatient surgery for removal of a cyst on her back. Her mother puts the hospital gown on her, but the child is crying because she wants to leave on her underpants. What is the most appropriate nursing action at this time?
- A. Allow her to wear her underpants.
- B. Discuss with her mother why this is important to the child.
- C. Ask her mother to explain to her why she cannot wear them.
- D. Explain in a kind, matter-of-fact manner that this is hospital policy.
Correct Answer: A
Rationale: Allowing the child to keep her underpants on provides a sense of control and comfort, and they can be removed later if needed for anesthesia. Discussing with the mother or citing hospital policy doesn?t address the child?s distress, and asking the mother to explain may escalate the situation.
A toddler is being sent to the operating room for surgery at 9 AM. As the nurse prepares the child, what is the priority intervention?
- A. Administering preoperative antibiotic
- B. Verifying that the child and procedure are correct
- C. Ensuring that the toddler has been NPO since midnight
- D. Informing the parents where they can wait during the procedure
Correct Answer: B
Rationale: Verifying the correct child and procedure is the priority to ensure safety and prevent errors. Administering antibiotics is secondary, clear liquids can be given up to 2 hours before surgery, and informing parents about waiting areas is important but not the priority.