Nokea
A 6-year-old child with sickle cell anemia presents to the emergency department with severe pain in the legs and abdomen. The child is crying and states that the pain is unbearable. What is the nurse's priority action?
- A. Apply warm compresses to the painful areas
- B. Administer prescribed pain medication
- C. Encourage the child to drink fluids
- D. Monitor the child's oxygen saturation
Correct Answer: B
Rationale: In a sickle cell crisis, pain management is a priority to alleviate the child's suffering. Administering the prescribed pain medication is crucial to address the severe pain experienced by the child. Warm compresses, fluid intake, and oxygen saturation monitoring are important interventions but should follow the priority of pain management in this situation.
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A 10-year-old girl who has had type 1 diabetes mellitus (DM) for the past two years tells the nurse that she would like to use a pump instead of insulin injections to manage her diabetes. Which assessment of the girl is most important for the nurse to obtain?
- A. Understanding of the quality control process used to troubleshoot the pump
- B. Interpretation of fingerstick glucose levels that influence diet selections
- C. Knowledge of her glycosylated hemoglobin A1c levels for the past year
- D. Ability to perform the pump for basal insulin with mealtime boluses
Correct Answer: A
Rationale: In a patient transitioning to an insulin pump, understanding the quality control process to troubleshoot the pump is essential for ensuring proper and safe management of diabetes. This knowledge enables the individual to identify and address any issues that may arise with the pump, helping maintain optimal glycemic control and prevent complications.
A 7-year-old child with a history of asthma is brought to the emergency department with an acute asthma exacerbation. The child is wheezing and using accessory muscles to breathe. What is the nurse's priority intervention?
- A. Administer a nebulized bronchodilator
- B. Obtain an arterial blood gas
- C. Start the child on oxygen therapy
- D. Notify the healthcare provider
Correct Answer: A
Rationale: In a 7-year-old child with an acute asthma exacerbation showing signs of wheezing and increased work of breathing, the priority intervention for the nurse is to administer a nebulized bronchodilator immediately. Bronchodilators help dilate the airways, relieve bronchospasm, and improve breathing, which is crucial in managing an acute asthma attack and preventing further respiratory distress.
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.
The mother of a one-month-old calls the clinic to report that the back of her infant's head is flat. How should the nurse respond?
- A. Turn the infant on the left side braced against the crib when sleeping.
- B. Prop the infant in a sitting position with a cushion when not sleeping.
- C. Place a small pillow under the infant's head while lying on the back.
- D. Position the infant on the stomach occasionally when awake and active.
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
An adolescent's mother calls the primary HCP's office to inquire about the results of her daughter's serum test that was drawn last week. Since it is the teenager's 18th birthday, how should the nurse respond to this mother's inquiry?
- A. Ask when the adolescent was last seen at the clinic
- B. Tell the mother to have the teenager call the clinic
- C. Provide the mother with the findings
- D. Explain that the information cannot be released without the 18-year-old's permission
Correct Answer: D
Rationale: When an individual turns 18, they are legally considered an adult, and privacy laws mandate that their consent is required before sharing their medical information with others. It is important to respect the adolescent's autonomy and privacy rights by explaining to the mother that the information cannot be disclosed without the 18-year-old's permission.