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A 7-year-old child is admitted to the hospital with nephrotic syndrome. The nurse notes that the child has gained 3 pounds in the past 24 hours. What should the nurse do first?
- A. Administer a diuretic as prescribed
- B. Restrict the child's fluid intake
- C. Notify the healthcare provider
- D. Measure the child's abdominal girth
Correct Answer: C
Rationale: In a child with nephrotic syndrome experiencing sudden weight gain, the priority action for the nurse is to notify the healthcare provider. This weight gain could indicate worsening edema or fluid retention, necessitating immediate medical evaluation and intervention. The healthcare provider can conduct a comprehensive assessment, order necessary tests, and adjust the treatment plan accordingly. Administering a diuretic, restricting fluid intake, or measuring abdominal girth should not be initiated without healthcare provider consultation to ensure appropriate management of the child's condition.
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The healthcare provider finds a 6-month-old infant unresponsive and calls for help. After opening the airway and finding the infant is still not breathing, which action should the provider take?
- A. Palpate femoral pulse and check for regularity.
- B. Deliver cycles of 30 chest compressions and 2 breaths.
- C. Give two breaths that make the chest rise.
- D. Feel the carotid pulse and check for adequate breathing.
Correct Answer: C
Rationale: In pediatric basic life support, for an unresponsive infant who is not breathing normally, the correct action is to give two breaths that make the chest rise. This helps provide oxygen to the infant's body and is a crucial step in resuscitation efforts for infants in distress. Choices A, B, and D are incorrect. Palpating the femoral pulse or feeling the carotid pulse is not indicated in this scenario where the infant is unresponsive and not breathing. Delivering cycles of chest compressions and breaths is not the immediate action to take; the priority is to provide two breaths to help with oxygenation.
A 7-year-old is admitted to the hospital with persistent vomiting, and a nasogastric tube attached to low intermittent suction is applied. Which finding is most important for the nurse to report to the healthcare provider?
- A. Gastric output of 100 mL in the last 8 hours.
- B. Shift intake of 640 mL IV fluids plus 30 mL PO ice chips.
- C. Serum potassium of 3.0 mEq/L.
- D. Serum pH of 7.45.
Correct Answer: C
Rationale: A serum potassium level of 3.0 mEq/L is significantly low and indicates hypokalemia, which can lead to serious complications such as cardiac arrhythmias. Therefore, it is crucial for the nurse to report this finding promptly to the healthcare provider for immediate intervention. The other findings are not as critical in this situation. Gastric output of 100 mL in the last 8 hours may be expected in a patient with persistent vomiting. The shift intake of IV fluids and ice chips indicates fluid replacement, which is important but not as urgent as correcting electrolyte imbalances. A serum pH of 7.45 is within the normal range and does not indicate an immediate concern.
A 16-year-old adolescent is admitted to the hospital with a diagnosis of meningitis. The nurse notes that the client has a severe headache and photophobia. What is the nurse's priority action?
- A. Administer prescribed pain medication
- B. Place the client in a dark, quiet room
- C. Notify the healthcare provider
- D. Encourage the client to rest
Correct Answer: B
Rationale: The priority action for the nurse when a client with meningitis presents with a severe headache and photophobia is to place the client in a dark, quiet room. This intervention helps reduce stimuli that can exacerbate symptoms such as headache and photophobia. Creating a calm environment can provide relief and promote comfort for the client while also supporting their recovery. Administering pain medication may be necessary but ensuring a suitable environment takes precedence. Notifying the healthcare provider is important but is not the immediate priority. Encouraging rest is beneficial, but creating an appropriate environment to alleviate symptoms is the initial essential step.
The healthcare provider plans to administer 10 mcg/kg of digoxin elixir as a loading dose to a child who weighs 55 pounds. Digoxin is available as an elixir of 50 mcg/ml. How many milliliters of the digoxin elixir should the healthcare provider administer to this child?
- A. 5 ml
- B. 10 ml
- C. 15 ml
- D. 20 ml
Correct Answer: A
Rationale: To calculate the dose, first, convert the child's weight to kilograms by dividing 55 pounds by 2.2, which equals approximately 25 kg. Then, multiply the weight by the dose (10 mcg/kg) to get the total dose needed, which is 250 mcg. Next, divide the total dose by the concentration of the elixir (50 mcg/ml) to determine the volume needed, which is 5 ml. Therefore, the correct dose is 5 ml based on the child's weight and the concentration of the elixir.
Which statement by a school-aged client going to summer camp indicates the best understanding of the mode of transmission of Lyme disease?
- A. I'll cover my mouth with a wet cloth if there's too much dust blowing.
- B. Cuts and scrapes need to be washed out and covered right away.
- C. I'm not going to swim where the water is standing still or feels too hot.
- D. I have to wear long sleeves and pants when we're hiking around the pond.
Correct Answer: D
Rationale: The correct answer is D. Wearing long sleeves and pants is an effective measure to prevent tick bites, which can transmit Lyme disease. Ticks are commonly found in wooded areas and tall grass, so covering exposed skin helps reduce the risk of tick bites and subsequently lowers the risk of contracting Lyme disease. Choices A, B, and C do not directly address the mode of transmission of Lyme disease. Option A pertains to respiratory protection against dust, Option B focuses on wound care, and Option C relates to water safety, none of which are directly related to preventing Lyme disease transmission.