Nokea
A nurse in an emergency department is caring for a 3-month-old infant. Which of the following actions should the nurse take?
- A. Administer ceftriaxone.
- B. Administer pneumococcal conjugate vaccine.
- C. Initiate serum glucose testing every 1 hr.
- D. Initiate neutropenic precautions.
Correct Answer: A
Rationale: The correct answer is A: Administer ceftriaxone. In infants, ceftriaxone is commonly used for treating bacterial infections due to its broad-spectrum coverage. It is important to initiate prompt treatment in infants to prevent complications. Administering a pneumococcal conjugate vaccine (choice B) is important for prevention but not an immediate action in this scenario. Initiating serum glucose testing every 1 hr (choice C) is not necessary unless there are specific indications, as it may cause unnecessary stress to the infant. Neutropenic precautions (choice D) are not relevant in this case as there is no indication of neutropenia.
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Which of the following actions should the nurse take first?
- A. Observe the child's throat with a flashlight.
- B. Give the child small sips of water.
- C. Administer an analgesic.
- D. Offer the child an ice collar.
Correct Answer: A
Rationale: The correct answer is A: Observe the child's throat with a flashlight. This is the first action the nurse should take as it helps assess for any signs of inflammation, infection, or obstruction in the throat, which could be causing the child's symptoms. By observing the throat, the nurse can gather important information to guide further interventions.
Choice B: Giving the child small sips of water can be important but should come after assessing the throat to ensure it is safe to swallow. Choice C: Administering an analgesic should be based on the assessment findings, not the first action. Choice D: Offering an ice collar is not indicated until the cause of the symptoms is identified.
Which of the following actions should the nurse take first?
- A. Check the pH of the gastric secretions.
- B. Set the administration rate on the feeding pump.
- C. Flush the tube with water.
- D. Attach the feeding bag tubing to the end of the NG tube.
Correct Answer: C
Rationale: The nurse should first flush the tube with water to ensure patency and prevent clogging. This step clears any residual medication or debris, allowing for safe and effective administration of feedings. Checking the pH of gastric secretions (A) is important but can be done after ensuring tube patency. Setting the administration rate (B) and attaching the feeding bag tubing (D) are premature without confirming tube patency. The correct order prioritizes patient safety and optimal feeding delivery.
Which of the following statements by the parent indicates an understanding of the teaching?
- A. My child might experience mood swings.
- B. I should take my child to the clinic for a weekly blood test.
- C. I should withhold my child's medication before physical activity.
- D. My child might have a decreased appetite.
Correct Answer: A
Rationale: The correct answer is A: "My child might experience mood swings." This statement shows understanding as mood swings can be a side effect of the medication being discussed. It demonstrates awareness of potential effects and indicates readiness to handle them. Choice B is incorrect as weekly blood tests are not typically necessary. Choice C is incorrect as withholding medication before physical activity can be dangerous. Choice D is incorrect as a decreased appetite is not a common side effect.
Which of the following findings should the nurse report to the provider?
- A. Drainage from the chest tube of 22 mL in the last hour
- B. Urine output of 15 mL in the last 2 hr
- C. Skin temperature 36° C (96.8° F)
- D. Pedal and posterior tibial pulses of 2+
Correct Answer: B
Rationale: The correct answer is B: Urine output of 15 mL in the last 2 hr. Inadequate urine output can indicate renal impairment or inadequate fluid intake. This is a critical finding that needs immediate attention to prevent further complications like acute kidney injury. A: Drainage from the chest tube of 22 mL in the last hour is within the normal range. C: Skin temperature of 36°C (96.8°F) is within normal limits. D: Pedal and posterior tibial pulses of 2+ indicate normal circulation.
Which of the following statements should the nurse include?
- A. Notify the provider if your child has dark brown blood between their teeth.
- B. Encourage your child to drink liquids through a straw.
- C. Notify the provider if your child is swallowing frequently.
- D. Encourage your child to clear their throat as needed.
Correct Answer: C
Rationale: The correct answer is C, "Notify the provider if your child is swallowing frequently." This statement is important as frequent swallowing may indicate potential issues such as aspiration or difficulty swallowing. It is crucial for the nurse to be aware of this symptom to ensure timely intervention.
Choice A is incorrect because dark brown blood between the teeth is not a typical symptom that would require immediate notification to the provider. Choice B is also incorrect as encouraging a child to drink through a straw may not be relevant to the situation at hand. Choice D is incorrect as clearing the throat as needed may not address the underlying issue of frequent swallowing.