Nokea
A client admitted to a surgical unit is being evaluated for an intestinal obstruction. The healthcare provider prescribes a nasogastric tube (NGT) to be inserted and placed to intermittent low wall suction. Which intervention should the nurse implement to facilitate proper tube placement?
- A. Soak nasogastric tube in warm water
- B. Insert tube with client's head tilted back
- C. Apply suction while inserting tube
- D. Elevate head of bed 60 to 90 degrees
Correct Answer: D
Rationale: Elevating the head of the bed helps facilitate proper placement of the NGT and reduces the risk of aspiration.
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The parent of a 1-year-old child with tetralogy of Fallot asks the nurse, “Why do my child’s fingertips look like that?†On what understanding does the nurse base a response?
- A. Clubbing occurs as a result of untreated congestive heart failure.
- B. Clubbing occurs as a result of a left-to-right shunting of blood.
- C. Clubbing occurs as a result of decreased cardiac output.
- D. Clubbing occurs as a result of chronic hypoxia.
Correct Answer: D
Rationale: Clubbing of the fingers develops in response to chronic hypoxia.
Which action by the school nurse is important in the prevention of rheumatic fever?
- A. Encourage routine cholesterol screenings.
- B. Conduct routine blood pressure screenings.
- C. Refer children with sore throats for throat cultures.
- D. Recommend salicylates instead of acetaminophen for minor discomforts.
Correct Answer: C
Rationale: Nurses have a role in prevention—primarily in screening school-age children for sore throats caused by group A β-hemolytic streptococci. They can achieve this by actively participating in throat culture screening or by referring children with possible streptococcal sore throats for testing. Cholesterol and blood pressure screenings do not facilitate the recognition and treatment of group A β-hemolytic streptococci. Salicylates should be avoided routinely because of the risk of Reye syndrome after viral illnesses.
Seventy-two hours after cardiac surgery, a young child has a temperature of 101° F. Which action should the nurse take?
- A. Keep child warm with blankets.
- B. Apply a hypothermia blanket.
- C. Record temperature on nurses’ notes.
- D. Report findings to physician.
Correct Answer: D
Rationale: In the first 24 to 48 hours after surgery, the body temperature may increase to 37.7° C (100° F) as part of the inflammatory response to tissue trauma. If the temperature is higher or continues after this period, it is most likely a sign of an infection and immediate investigation is indicated. Blankets should be removed from the child to keep the temperature from increasing. Hypothermia blanket is not indicated for this level of temperature. The temperature should be recorded, but the physician must be notified for evaluation. Suctioning should be done only as indicated, not on a routine basis. The child should be suctioned for no more than 5 seconds at one time. Symptoms of respiratory distress are avoided by using appropriate technique.
Treatment options in the management of an intussusception include:
- A. Contrast enema
- B. Air enema
- C. Water enema
- D. Open surgery
Correct Answer: B
Rationale: Air enema is a common non-surgical treatment for intussusception. Contrast enema and open surgery are also options, but air enema is often preferred.
A 12-year-old child whose weight and body mass index (BMI) are in the 75th percentile has a diastolic blood pressure that is between the 95th and 99th percentiles for age, sex, and height on three separate occasions. Which test will be prescribed for this child initially?
- A. complete blood count
- B. erythrocyte sedimentation rate
- C. urinalysis and electrolytes
- D. renal function
Correct Answer: C
Rationale: Since the majority of children with stage 1 or 2 hypertension have renal or renovascular causes for elevated BP, renal function and plasma renin tests should be performed.