Nokea
A child has a central venous access device for intravenous (IV) fluid administration. A blood sample is needed for a complete blood count, hemogram, and electrolytes. What is the appropriate procedure to implement for this blood sample?
- A. Perform a new venipuncture to obtain the blood sample.
- B. Interrupt the IV fluid and withdraw the blood sample needed.
- C. Withdraw a blood sample equal to the amount of fluid in the device, discard, and then withdraw the sample needed.
- D. Flush the line and central venous device with saline and then aspirate the required amount of blood for the sample.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A mother delivers an infant at 30 weeks gestation. The mother asks the nurse for information on nutrition and if formula would be better since the baby is premature. What is the foundation for the response to the mother by the nurse?
- A. Human milk is preferred over other types of nutrition.
- B. Human milk lacks essential nutrients when the infant is preterm.
- C. Commercial infant formulas are preferred over other types of nutrition.
- D. Commercial infant formulas have not been designed to meet the nutritional needs of preterm infants.
Correct Answer: A
Rationale: The correct answer is A. Human milk is the preferred food for infants, including preterm infants. It contains essential ingredients necessary for the infant's growth and development. The mother should pump her breasts to provide milk for the infant if the child is receiving enteral feedings. Once the infant can coordinate breathing, sucking, and swallowing, breastfeeding directly is encouraged. Studies have shown that preterm infants fed fortified human milk have better outcomes compared to those fed commercial infant formulas. Commercial infant formulas may not fully meet the unique nutritional needs of preterm infants, leading to potential longer hospital stays. Therefore, human milk is the best choice for feeding premature infants.
Which nursing action is developmentally appropriate when caring for a hospitalized school-age child?
- A. Providing brochures regarding sexuality
- B. Giving clear instructions about details of treatment
- C. Offering medical equipment to play with prior to a procedure
- D. Using toys for distraction during a painful procedure
Correct Answer: C
Rationale: Offering medical equipment to play with prior to a procedure is developmentally appropriate when caring for a hospitalized school-age child. Allowing the child to familiarize themselves with the equipment helps reduce fear and anxiety about the upcoming procedure. Choices A, B, and D are not as appropriate for a school-age child. Providing brochures regarding sexuality is not developmentally appropriate for this age group. Giving clear instructions about treatment details may overwhelm a child of this age. Using toys for distraction during a painful procedure is more suitable for younger children.
The nurse is teaching parents guidelines for feeding their 8-month-old infant with failure to thrive (FTT). Which statement by the parents indicates a need for further teaching?
- A. We will continue to use the 24-kcal/oz formula.
- B. We will be sure to follow the formula preparation instructions.
- C. We will be sure to give our infant at least 8 oz of juice every day.
- D. We will be sure to feed our infant according to the written schedule.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
When checking the intravenous (IV) site on a child, the nurse should take which action?
- A. Look at the site.
- B. Ask the child if the site hurts.
- C. Look at the site while palpating the area.
- D. Take all the tape off, assess the site, and redress.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What type of shock is characterized by a hypersensitivity reaction causing massive vasodilation and capillary leaks, which may occur with drug or latex allergy?
- A. Neurogenic shock
- B. Cardiogenic shock
- C. Hypovolemic shock
- D. Anaphylactic shock
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.