Nokea
A child with cystic fibrosis is receiving gentamicin. Which of the following nursing actions is most important?
- A. Monitoring intake and output.
- B. Obtaining daily weights.
- C. Monitoring the client for indications of constipation.
- D. Obtaining stool samples for hemoccult testing.
Correct Answer: A
Rationale: Monitoring intake and output is critical when administering gentamicin, an aminoglycoside, to detect early signs of nephrotoxicity, a common adverse effect.
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A school-age child who has received burns over 60% of his body is to receive 2,000 mL of I.V. fluid over the next 8 hours. At what rate (in milliliters per hour) should the nurse set the infusion pump?
Correct Answer: 250
Rationale: Dividing 2,000 mL by 8 hours yields 250 mL/hour. This ensures fluid resuscitation meets burn protocol (e.g., Parkland formula) to maintain hemodynamic stability.
The nurse judges that the mother understands the diet restrictions for her child with chronic renal failure who is receiving peritoneal dialysis when she reports providing a diet involving which of the following?
- A. Sodium and water restrictions.
- B. High protein and carbohydrates.
- C. High potassium and iron.
- D. Protein and phosphorus restrictions.
Correct Answer: A
Rationale: Dietary restrictions help manage symptoms.
A 6-month old infant has had a cardiac arrest and the rapid response team has been paged. The nurse arrives in the client's room and observes a physician assistant (PA) administering CPR to an infant (see figure). To assist the PA with CPR, the nurse should:
- A. Tell the PA to use the heel of the hand on the infant's sternum.
- B. Place one hand on the infant's sternum for chest compressions while the PA ventilates the lungs at a rate of one breath to every 5 compressions.
- C. Obtain an Ambu bag and give breaths at a rate of 2 breaths per 15 compressions.
- D. Encircle the infant's chest with the thumbs=on top to provide compression while the PA uses an Ambu bag to administer rescue breaths after every 15 compressions.
Correct Answer: C
Rationale: For an infant, the nurse should obtain an Ambu bag and deliver 2 breaths per 15 compressions, following pediatric CPR guidelines for 2-rescuer CPR.
Which of the following statements by the mother of a toddler diagnosed with nephrotic syndrome indicates that the mother has understood the nurse's teaching about this disease?
- A. My child really likes chips and bologna. I guess we'll have to find something else.
- B. We'll have to encourage lots of liquids. Did you say about 4 liters every day?
- C. We worry about the surgery. Do you think we should do direct donation of blood?
- D. We understand the need for antibiotics. I just wish the antibiotics could be given by mouth.
Correct Answer: A
Rationale: Shows understanding of dietary restrictions.
A nurse identifies a medication error in a pediatric unit. Which action should the nurse take first?
- A. Administer the correct medication.
- B. Notify the prescribing physician.
- C. Complete an incident report.
- D. Inform the child's parents.
Correct Answer: C
Rationale: Completing an incident report ensures documentation and system improvement. Correcting the medication, notifying the physician, or informing parents follows after reporting.