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A nurse at a pediatric hotline receives a call from a mother who plans to administer aspirin to a toddler for a fever and wants to know the dosage. Which of the following statements by the nurse is an appropriate response?
- A. Follow the directions on the aspirin bottle for her age and weight.'
- B. She should be given acetaminophen, not aspirin.'
- C. Just be sure you administer the medication with food.'
- D. Give her no more than three baby aspirin every 4 hours.'
Correct Answer: B
Rationale: It's not advisable to follow the directions on the aspirin bottle for her age and weight. Aspirin is not recommended for use in children due to the risk of Reye's syndrome, a rare but serious condition that can affect the liver and brain. This is the correct response. Acetaminophen is a safer alternative to aspirin for managing fever in children. While it's generally a good idea to administer medication with food to prevent stomach upset, this advice does not address the specific risks associated with giving aspirin to a toddler. Giving a toddler three baby aspirin every 4 hours is not recommended due to the risk of Reye's syndrome.
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A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority?
- A. Place a pillow under the child's head.
- B. Remove the child's eyeglasses.
- C. Time the seizure.
- D. Move the child into a side-lying position.
Correct Answer: D
Rationale: While placing a pillow under the child's head might seem like a good idea, it's actually not recommended during a seizure. The child's movements could be unpredictable, and a pillow could potentially cause suffocation. Removing the child's eyeglasses is a good idea, but it's not the first thing you should do. The child's safety is the top priority, and eyeglasses can be removed once the child is safe. Timing the seizure is important for medical professionals to know, but it's not the first action to take. The child's immediate safety is the priority. Moving the child into a side-lying position is the priority. This position helps keep the airway clear and allows any vomit to exit the mouth, reducing the risk of choking.
A 10-year-old child was admitted with full-thickness burns affecting more than 15% of the child's body surface. What manifestations of hypovolemic shock would you observe for over the next 48 hrs? Select all choices that apply:
- A. Rapid pulse.
- B. Decreased B/P.
- C. Pallor.
- D. Flushed Face.
Correct Answer: A,B,C
Rationale: Choice A rationale: Rapid pulse is a common manifestation of hypovolemic shock. When the body experiences a significant loss of fluid, such as in severe burns, the heart rate increases in an attempt to maintain adequate blood flow and oxygen delivery to the body's tissues. Choice B rationale: Decreased blood pressure is another typical sign of hypovolemic shock. As the body loses fluid, the volume of blood circulating through the body decreases. This drop in blood volume leads to a decrease in blood pressure. Choice C rationale: Pallor, or paleness of the skin, can occur in hypovolemic shock. This happens because the body prioritizes sending blood to vital organs like the heart and brain, which can result in less blood flow to the skin, causing it to appear pale. Choice D rationale: A flushed face is not typically associated with hypovolemic shock. In fact, the skin may actually appear pale or cool due to reduced blood flow.
A nurse is providing guidance to a toddler's parent about the types of food that are part of a clear liquid diet. Which food, if suggested by the parent, would indicate that they have understood the instructions?
- A. Yogurt
- B. Gelatin
- C. Strained soup
- D. Pureed fruit
Correct Answer: B
Rationale: Yogurt is not part of a clear liquid diet. It is a dairy product and is not clear or liquid at room temperature. Gelatin is part of a clear liquid diet. This type of diet is often prescribed before medical procedures or tests, or for patients with certain digestive issues. It consists of liquids and foods that are clear and liquid at room temperature. Strained soup might be allowed on a full liquid diet, but it is not part of a clear liquid diet. Only the broth of the soup, which is clear and liquid at room temperature, would be allowed. Pureed fruit is not part of a clear liquid diet. While it is a liquid at room temperature, it is not clear.
How many mL of fluid intake should the nurse record for a client who consumed 1 cup of coffee, 4 oz of orange juice, 3 oz of water, 1 cup of flavored gelatin, 1 cup of tea, 5 oz of broth, and 3 oz of water during a 4-hour period? (Round the answer to the nearest whole number)
Correct Answer: 1170 mL
Rationale: Step 1 is to convert all fluid intake to mL. Using the conversion factor 1 oz = 30 mL and 1 cup = 240 mL, we get: 1 cup of coffee = 240 mL, 4 oz of orange juice = 4 × 30 mL = 120 mL, 3 oz of water = 3 × 30 mL = 90 mL, 1 cup of flavored gelatin = 240 mL, 1 cup of tea = 240 mL, 5 oz of broth = 5 × 30 mL = 150 mL, 3 oz of water = 3 × 30 mL = 90 mL. Step 2 is to add up all the mL values: 240 mL (coffee) + 120 mL (orange juice) + 90 mL (water) + 240 mL (gelatin) + 240 mL(tea) + 150 mL (broth) + 90 mL (water) = 1170 mL. So, the nurse should record a fluid intake of 1170 mL.
A nurse is collecting data from a child who has acute appendicitis. Which of the following findings should the nurse expect?
- A. Bradycardia
- B. Hyperactive bowel sounds
- C. WBC 17,000/mm
- D. Left lower quadrant abdominal pain
Correct Answer: C
Rationale: Bradycardia, or a slower than normal heart rate, is not typically associated with acute appendicitis. In fact, tachycardia, or a faster than normal heart rate, may occur due to the body's response to inflammation and infection. Hyperactive bowel sounds are not a typical finding in acute appendicitis. In fact, bowel sounds may be normal or decreased due to the inflammatory process. A white blood cell (WBC) count of 17,000/mm is higher than the normal range, indicating the presence of an infection or inflammation in the body. This is a common finding in acute appendicitis. Pain from appendicitis is typically located in the right lower quadrant of the abdomen, not the left.