Nokea
A nasogastric tube inserted during surgery to correct an infant's intussusception is no longer freely removing gastric secretions. Which of the following should the nurse do next?
- A. Aspirate the tube with a syringe.
- B. Irrigate the tube with distilled water.
- C. Increase the level of suction.
- D. Rotate the tube.
Correct Answer: A
Rationale: Aspirating with a syringe checks for blockages and attempts to restore function safely.
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To assess a 9-year-old's social development, the nurse asks the parent if the child:
- A. Thinks independently.
- B. Is able to organize and plan.
- C. Has a best friend.
- D. Enjoys active play.
Correct Answer: C
Rationale: Having a best friend indicates healthy social development at 9 years.
A nurse is assessing a child who is mildly mentally retarded. The best indication of how a mentally retarded child is progressing can be obtained by observing him:
- A. At school with his teacher.
- B. At home with his family.
- C. In the clinic with his mother.
- D. Playing soccer with his friends.
Correct Answer: B
Rationale: Observing the child at home provides insight into daily functioning and adaptive behavior in a familiar environment, reflecting progress accurately.
When planning a visit to the parents of an infant who died of sudden infant death syndrome (SIDS) at home, the nurse should visit the parents at which of the following times?
- A. A few days after the funeral.
- B. Two weeks after the funeral.
- C. As soon as the parents are ready to talk.
- D. As soon after the infant's death as possible.
Correct Answer: C
Rationale: Visiting as soon as the parents are ready to talk respects their grieving process and ensures they are emotionally prepared to receive support.
A 7-year-old child is experiencing pain after an appendectomy. Which data collection tool should the nurse use to assess the pain?
- A. Visual analog scale.
- B. Short Form McGill Questionnaire.
- C. FACES Pain Rating Scale.
- D. Numeric Pain Intensity Scale.
Correct Answer: C
Rationale: The FACES scale is age-appropriate for a 7-year-old to assess pain.
A child with Kawasaki disease is receiving low dose aspirin. The mother calls the clinic and states that the child has been exposed to influenza. Which recommendations should the nurse make?
- A. Increase fluid intake.
- B. Stop the aspirin.
- C. Keep the child home from school.
- D. Watch for fever.
- E. Weigh the child daily.
Correct Answer: B,C,D
Rationale: Aspirin should be stopped due to the risk of Reye's syndrome with influenza. Keeping the child home and monitoring for fever help manage infection risk.