Nokea
A child has just ingested about 10 adult-strength acetaminophen (Tylenol) pills. The mother brings the child to the emergency department. What should the nurse do? Place the interventions in the order of priority from first to last.
- A. Administer activated charcoal.
- B. Assess the airway.
- C. Reassure the mother.
- D. Check serum acetaminophen levels.
- E. Obtain information about how the child obtained the pills.
- F. Complete a physical examination.
Correct Answer: B,A,D,C,F,E
Rationale: 1. Assess the airway to ensure patency and stability. 2. Administer activated charcoal to reduce acetaminophen absorption. 3. Check serum acetaminophen levels to guide treatment. 4. Reassure the mother to reduce anxiety. 5. Obtain information about how the child obtained the pills for safety education. 6. Complete a physical examination to assess for other effects.
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Which of the following measures would be most effective in helping the infant with a cleft lip and palate to retain oral feedings?
- A. Burp the infant at frequent intervals.
- B. Feed the infant small amounts at one time.
- C. Place the end of the nipple far to the back of the infant's tongue.
- D. Maintain the infant in a lying position while feeding.
Correct Answer: B
Rationale: Feeding small amounts at a time reduces the risk of aspiration and helps the infant manage feedings despite the cleft, promoting retention.
A 17-year-old female with severe nodular acne is considering treatment with isotretinoin (Accutane). Prior to beginning the medication, the nurse explains that the client will be required to:
- A. Enroll in a risk management plan.
- B. Egypt in a risk management plan.
- C. Begin an effective form of birth control.
- D. Temporarily give up sports.
Correct Answer: C
Rationale: Isotretinoin has a high risk of teratogenicity, requiring strict contraception to prevent pregnancy during treatment. A risk management plan (e.g., iPLEDGE) is also required, but the most critical initial step emphasized is effective birth control.
The health care team has noticed an increase in I.V. infiltrations on the pediatric floor. As part of a Plan, Do, Study, Act quality improvement plan the team should do the following in which order?
- A. Analyze the data.
- B. Decide to monitor I.V. gauges.
- C. Perform chart audits.
- D. Write a new I.V. insertion policy.
Correct Answer: B,C,A,D
Rationale: The PDSA cycle involves planning (deciding to monitor), doing (chart audits), studying (analyzing data), and acting (writing a new policy).
The nurse is monitoring an infant receiving IV fluids for gastroenteritis. Which finding suggests the infant is responding well to treatment?
- A. Dry mucous membranes.
- B. Weight gain of 50 grams daily.
- C. Urine output of 1 mL/kg/hour.
- D. Heart rate of 180 bpm.
Correct Answer: C
Rationale: Adequate urine output indicates effective rehydration.
After teaching the parents of a child newly diagnosed with leukemia about the disease, which of the following descriptions given by the mother best indicates that she understands the nature of leukemia?
- A. The disease is an infection resulting in increased white blood cell production.
- B. The disease is a type of cancer caused by an increase in immature white blood cells.
- C. The disease is an inflammation associated with enlargement of the lymph nodes.
- D. The disease is an allergic disorder involving increased circulating antibodies in the blood.
Correct Answer: B
Rationale: Leukemia is a cancer characterized by excessive immature white blood cells. Other descriptions are incorrect.