Nokea
A nurse administers ranitidine (Zantac) instead of cetirizine (Zyrtec) to an 8-year-old with asthma. The client has suffered no adverse effects. The nurse tells the charge nurse of the incident but fears disciplinary action. The charge nurse should tell the nurse:
- A. If you do not report the error, I will have to.
- B. Reporting the error helps to identify system problems to improve client safety.
- C. Notify the client's physician to see if she wants this reported.
- D. This is not a serious mistake so reporting it will not affect your position.
Correct Answer: B
Rationale: Reporting the error helps identify system problems to improve client safety, promoting a culture of transparency and quality improvement.
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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 is preparing to administer furosemide (Lasix) to a 3-year-old with a heart defect. The nurse verifies the child's identity by checking the arm band and:
- A. Asking the child to state her name.
- B. Checking the room number.
- C. Asking the child to tell her birth date.
- D. Asking the parent the child's name.
Correct Answer: D
Rationale: Asking the parent is appropriate for a 3-year-old, who may not reliably state their name or birth date. Room numbers are not reliable identifiers.
When developing a teaching plan for the parents of a child with Down syndrome, the nurse focuses on activities to increase which of the following for the parents?
- A. Affection for their child.
- B. Responsibility for their child's welfare.
- C. Understanding of their child's disability.
- D. Confidence in their ability to care for their child.
Correct Answer: D
Rationale: Building parental confidence empowers them to manage their child's needs effectively, fostering positive outcomes.
A 14-year-old girl with sickle cell disease has her fourth hospitalization for sickle cell crisis. Her family is planning a ski vacation in the mountains. What should the nurse tell the parents?
- A. Encourage them to go on the trip.
- B. Go on the trip, but find a sitter for the 14-year-old.
- C. Suggest the trip be postponed until next year.
- D. Explain that the high altitude may cause a crisis.
Correct Answer: D
Rationale: High altitudes reduce oxygen availability, increasing the risk of sickle cell crisis due to hypoxia. This is a critical consideration for the child's safety.
Which of the following assessments would be most important for the nurse to make initially in a school-age child being seen in the clinic who has a sore throat, muscle tenderness, arms feeling weak, and generally is not feeling well?
- A. Difficulty swallowing.
- B. Recent history of viral infection.
- C. Presence of fever.
- D. History of recent trauma.
Correct Answer: A
Rationale: Difficulty swallowing indicates potential cranial nerve involvement, a critical early sign in Guillain-Barré syndrome, requiring immediate attention.