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A child with asthma who weighs 4.69 kg
A child with asthma has the following medication ordered: Theophylline 4 mg/kg/dose every 6 hrs. The child weighs 4.69 kg. Calculate the appropriate dose.
- A. 33.6 mg
- B. 18.7 mg
- C. 8.4 mg
- D. 19 mg
Correct Answer: B
Rationale: To calculate the appropriate dose for the child, we first need to determine the child's weight in mg: 4.69 kg x 4 mg/kg = 18.76 mg. Since the dose is rounded to the nearest tenth, the correct dose is 18.7 mg (choice B). This calculation ensures the child receives the correct amount of medication based on their weight. Choices A, C, and D are incorrect as they do not accurately reflect the calculated dose.
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A client who is postoperative immediately following a tonsillectomy
A nurse is caring for a client who is postoperative immediately following a tonsillectomy. Which of the flowing snacks should the nurse offer the client?
- A. Cranberry juice
- B. Ice-cream
- C. Hot tea
- D. Italian ice
Correct Answer: B,D
Rationale: The correct snacks to offer a client post-tonsillectomy are ice-cream and Italian ice. Ice-cream is soft, cold, and soothing, helping to reduce pain and inflammation. Italian ice is also cold and can provide relief. Cranberry juice and hot tea are acidic and may irritate the surgical site. Ice-cream and Italian ice are the best choices as they are gentle on the throat and provide comfort without causing discomfort.
An infant who has developmental dysplasia of the hip (DDH)
A nurse is collecting data from an infant who has developmental dysplasia of the hip (DDH). Which of the following findings should the nurse expect?
- A. Inwardly turned foot on the affected side
- B. Lengthened thigh on the affected side
- C. Absent plantar reflexes
- D. Asymmetric thigh folds
Correct Answer: A,D
Rationale: The correct answers are A and D. In DDH, an inwardly turned foot on the affected side (A) is expected due to hip dislocation. Asymmetric thigh folds (D) are also common as the affected thigh may appear shorter due to dislocation. Lengthened thigh (B) is incorrect as the thigh may appear shortened. Absent plantar reflexes (C) are not typical in DDH.
A school-age child who has respiratory failure due to pneumonia
A nurse is assisting with the care of a school-age child who has respiratory failure due to pneumonia. Which of the following positions should the nurse encourage to allow maximal lung expansion?
- A. Upright
- B. Supine
- C. Prone
- D. Side-lying
Correct Answer: A
Rationale: The correct answer is A: Upright. In an upright position, gravity helps to maximize lung expansion by allowing the diaphragm to descend fully. This position promotes better ventilation and oxygenation by reducing the pressure on the lungs. Supine (B), prone (C), and side-lying (D) positions can limit lung expansion and compromise breathing mechanics. These positions may cause the abdominal contents to compress the lungs, reducing their ability to expand fully. Therefore, encouraging the child to sit upright will optimize lung function and promote effective gas exchange.
A newborn who has a myelomeningocele and is admitted to the newborn intensive care unit (NICU) to await surgery
A nurse is caring for a newborn who has a myelomeningocele and is admitted to the newborn intensive care unit (NICU) to await surgery. Which of the following nursing goals is priority in the care of this infant?
- A. Promote maternal-infant bonding
- B. Provide age-appropriate stimulation.
- C. Educate the parents about the defect.
- D. Maintain integrity of the sac.
Correct Answer: D
Rationale: The correct answer is D: Maintain integrity of the sac. This is the priority goal because the newborn with myelomeningocele is at risk for infection and further damage if the sac is not properly cared for. By ensuring the sac is clean, covered, and protected, the nurse can help prevent complications such as meningitis. Promoting maternal-infant bonding (A) is important but not the priority at this time. Providing age-appropriate stimulation (B) is not as urgent as ensuring the sac's integrity. Educating the parents about the defect (C) is crucial for long-term care but not the immediate priority.
A 3-month-old infant receiving oral elixir
A nurse is preparing to administer an oral elixir to a 3-month-old infant using an oral medication syringe. Which of the following actions should the nurse plan to take?
- A. Measure the elixir in a medicine cup before transferring to a syringe
- B. Place the infant supine in a crib prior to administration.
- C. Position the syringe to the side of the infant's tongue.
- D. Mix the medication with 10 mL of formula.
Correct Answer: C
Rationale: The correct answer is C: Position the syringe to the side of the infant's tongue. This is the correct action as it helps prevent choking and aspiration in infants. Placing the syringe to the side allows the infant to swallow the medication more effectively while reducing the risk of it going down the wrong pipe. It also encourages a natural swallowing reflex.
Choice A is incorrect because measuring in a medicine cup before transferring to a syringe may lead to inaccuracies in dosage. Choice B is incorrect as placing the infant supine increases the risk of choking. Choice D is incorrect as mixing medication with formula may interfere with the medication's effectiveness.