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A 6-year-old child with a history of asthma is brought to the clinic with complaints of wheezing and shortness of breath. The nurse notes that the child is using accessory muscles to breathe. What should the nurse do first?
- A. Administer a bronchodilator
- B. Obtain a peak flow reading
- C. Apply oxygen
- D. Perform a complete respiratory assessment
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A child with leukemia is admitted for chemotherapy, and the nursing diagnosis 'altered nutrition, less than body requirements related to anorexia, nausea, and vomiting' is identified. Which intervention should the nurse include in this child's plan of care?
- A. Encourage a variety of large portions of food at every meal.
- B. Allow the child to eat any food desired and tolerated.
- C. Recommend eating the food as siblings eat at home.
- D. Restrict food brought from fast food restaurants.
Correct Answer: B
Rationale: Allowing the child to eat any food desired and tolerated is the most appropriate intervention for a child with altered nutrition due to anorexia, nausea, and vomiting. It is crucial to prioritize maintaining adequate nutritional intake, and by allowing the child to choose foods they desire and can tolerate, the chances of improving their nutritional status increase. This approach helps in ensuring that the child receives necessary nutrients during chemotherapy, even if their appetite is affected by the treatment.
When should oral hygiene practices start for an infant according to the American Dental Association guidelines?
- A. There is no need to begin until after all of the child's baby teeth are in.
- B. You don't have to worry about that until your child can handle a toothbrush.
- C. You can begin now using toothpaste on a gauze pad and wiping the gums.
- D. Begin wiping the teeth with a washcloth and water when the first tooth appears.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The nurse is assessing a 4-year-old child who is brought to the clinic for a routine checkup. The child's parent reports that the child has been more irritable and less active over the past week. The nurse notes a petechial rash on the child's trunk and extremities. What should the nurse do first?
- A. Ask the parent about recent exposure to contagious diseases
- B. Review the child's immunization record
- C. Measure the child's temperature
- D. Notify the healthcare provider immediately
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
An infant with tetralogy of Fallot becomes acutely cyanotic and hyperpneic. Which action should the nurse implement first?
- A. Administer morphine sulfate.
- B. Start IV fluids.
- C. Place the infant in a knee-chest position.
- D. Provide 100% oxygen by face mask.
Correct Answer: C
Rationale: In a situation where an infant with tetralogy of Fallot is acutely cyanotic and hyperpneic, the priority action should be to place the infant in a knee-chest position. This position helps increase systemic vascular resistance, improving pulmonary blood flow and subsequently ameliorating the cyanosis and hyperpnea. It is a non-invasive and effective intervention that can be promptly implemented by the nurse to address the immediate respiratory distress.
The mother calls the clinic and tells the practical nurse (PN) that her child cannot swallow a prescribed tablet that was dispensed by the local pharmacy as a whole tablet. How should the PN respond?
- A. You can crush the tablet and mix it with food.
- B. You should not force the child to swallow the tablets by holding her nose closed.
- C. If a liquid form is available, the pharmacist can be contacted for a prescription change.
- D. Do not advise the child to chew the tablet if she cannot swallow it.
Correct Answer: C
Rationale: When a child is unable to swallow a tablet, the appropriate response is to consider if a liquid form of the medication is available. This is a safer and more effective alternative than forcing the child to swallow or chew the tablet. Contacting the pharmacist for a prescription change can provide a suitable solution that ensures the child receives the medication in a more manageable form.