Nokea
A child with a diagnosis of cystic fibrosis is admitted to the hospital. What is the priority nursing intervention?
- A. Administering pancreatic enzymes
- B. Providing respiratory therapy
- C. Providing nutritional support
- D. Encouraging physical activity
Correct Answer: A
Rationale: The correct answer is administering pancreatic enzymes. In cystic fibrosis, the pancreas is often affected, leading to insufficient production of digestive enzymes. Administering pancreatic enzymes is crucial to ensure proper digestion and absorption of nutrients. While respiratory therapy, nutritional support, and physical activity are essential components of care for individuals with cystic fibrosis, addressing the digestive aspect by administering pancreatic enzymes takes priority to prevent malnutrition and promote overall health.
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What explanation should the nurse give a parent about the purpose of a tetanus toxoid injection for their child?
- A. Passive immunity is conferred temporarily.
- B. Long-lasting active immunity is conferred.
- C. Lifelong active natural immunity is conferred.
- D. Passive natural immunity is conferred temporarily.
Correct Answer: B
Rationale: The correct answer is B: Long-lasting active immunity is conferred. Tetanus toxoid injection works by stimulating the child's body to produce its antibodies, providing long-lasting active immunity. Choice A is incorrect because passive immunity is not conferred for life; it is temporary and involves receiving antibodies rather than producing them internally. Choice C is incorrect as the immunity conferred by the tetanus toxoid injection is not lifelong natural immunity but rather active immunity stimulated by the body's immune response. Choice D is also incorrect since passive natural immunity is not conferred by the tetanus toxoid injection, and it is not temporary.
After a discussion with the health care provider, the parents of an infant with patent ductus arteriosus (PDA) ask the nurse to explain once again what PDA is. How should the nurse respond?
- A. The diameter of the aorta is enlarged.
- B. The wall between the right and left ventricles is open.
- C. It is a narrowing of the entrance to the pulmonary artery.
- D. It is a connection between the pulmonary artery and the aorta.
Correct Answer: D
Rationale: The correct answer is D: 'It is a connection between the pulmonary artery and the aorta.' Patent ductus arteriosus (PDA) is an abnormal connection between the pulmonary artery and the aorta, which normally closes after birth. Choices A, B, and C describe different cardiac conditions and do not accurately define PDA. Choice A is incorrect because PDA does not involve the diameter of the aorta being enlarged. Choice B is incorrect because PDA does not involve the wall between the right and left ventricles being open. Choice C is incorrect because PDA is not a narrowing of the entrance to the pulmonary artery.
When explaining the occurrence of febrile seizures to a parents' class, what information should the nurse include?
- A. They may occur in minor illnesses.
- B. The cause is usually readily identified.
- C. They usually do not occur during the toddler years.
- D. The frequency of occurrence is greater in females than males.
Correct Answer: A
Rationale: The correct answer is A: 'They may occur in minor illnesses.' Febrile seizures can occur even in minor illnesses, particularly in young children, and are often triggered by a rapid increase in body temperature. Choice B is incorrect because the cause of febrile seizures is not always readily identified. Choice C is incorrect as febrile seizures commonly occur in children between the ages of 6 months to 5 years, which includes the toddler years. Choice D is incorrect as febrile seizures are slightly more common in males than females.
The parents of a 6-month-old infant are concerned about the risk of sudden infant death syndrome (SIDS). What should the nurse recommend to reduce the risk?
- A. Place the infant on their back to sleep
- B. Use a pacifier during sleep
- C. Have the infant sleep on their side
- D. Keep the infant's room cool
Correct Answer: A
Rationale: The correct recommendation to reduce the risk of SIDS in infants is to place them on their back to sleep. This sleeping position helps prevent the occurrence of SIDS by maintaining an open airway and reducing the risk of suffocation. Using a pacifier during sleep has also shown some protective effect against SIDS, but it is not as effective as placing the infant on their back. Having the infant sleep on their side is not recommended as it can increase the risk of accidental suffocation. Keeping the infant's room cool does not directly reduce the risk of SIDS.
A child with a diagnosis of pyloric stenosis is scheduled for surgery. What preoperative intervention is important for the nurse to perform?
- A. Administering intravenous fluids
- B. Monitoring for signs of infection
- C. Monitoring for signs of dehydration
- D. Monitoring for signs of pain
Correct Answer: C
Rationale: The correct preoperative intervention for a child with pyloric stenosis is to monitor for signs of dehydration. Pyloric stenosis can lead to vomiting, which can result in dehydration. Monitoring for signs of dehydration is crucial to ensure the child's fluid balance is maintained. Administering intravenous fluids, although important for managing dehydration and electrolyte imbalances, would typically be done postoperatively rather than as a preoperative intervention. Monitoring for signs of infection is important but not specific to the preoperative period for pyloric stenosis. Monitoring for signs of pain is also important but may not be the most critical preoperative intervention in this scenario.