Nokea
A nurse is assessing a child who has measles. Which of the following areas should the nurse inspect for Koplik spots?
Correct Answer: C
Rationale: The correct answer is C. Koplik spots are small, white, grain-like spots with a red halo that appear on the buccal mucosa opposite the molars. They are specific to measles and typically appear 2-4 days before the rash. Inspecting other areas like the skin (choice A), scalp (choice B), nails (choice D), ears (choice E), throat (choice F), or feet (choice G) would not reveal Koplik spots as they are only found in the mouth. Therefore, choice C is the correct option for assessing Koplik spots in a child with measles.
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A nurse is caring for a child who has impetigo contagiosa and developed in the hospital. Which of the following actions should the nurse take?
- A. Report the infection to the state health department.
- B. Administer penicillin G, IV.
- C. Initiate contact isolation precautions.
- D. Apply a topical antifungal cream.
Correct Answer: C
Rationale: Correct Answer: C - Initiate contact isolation precautions.
Rationale: Impetigo contagiosa is highly contagious, caused by bacteria, not fungi. Contact isolation helps prevent the spread of infection. Reporting to the state health department is important, but immediate isolation is crucial. Administering penicillin G is not the first-line treatment for impetigo. Applying an antifungal cream is incorrect as impetigo is caused by bacteria, not fungi.
A nurse is caring for a 9-year-old child at a clinic. The nurse should determine that the assessment findings are consistent with which of the following conditions?
- A. Edema
- B. Ecchymosis
- C. Pain Level
- D. Sensation
Correct Answer: B
Rationale: The correct answer is B: Ecchymosis. Ecchymosis is the presence of bruising, which is commonly seen in cases of trauma such as sprains, fractures, and dislocations. In a 9-year-old child, ecchymosis may indicate underlying injury or trauma. Edema can also be present in sprains, fractures, and dislocations, but it is not specific to these conditions. Pain level is subjective and can vary depending on the individual, so it is not as definitive as ecchymosis in identifying a specific condition. Sensation is important to assess in cases of injury, but it is not as indicative of a specific condition as ecchymosis. Therefore, the presence of ecchymosis is the most specific assessment finding to determine the underlying condition in this case. (0, 1, 0)
A nurse is preparing to admit a 6-year-old with varicella to the pediatric unit. Which of the following actions should the nurse take?
- A. Assign the child to a negative air pressure room.
- B. Administer aspirin to the child for fever.
- C. Use droplet precautions when caring for the child.
- D. Assess the child for Koplik spots.
Correct Answer: A
Rationale: The correct answer is A: Assign the child to a negative air pressure room. Varicella, commonly known as chickenpox, is highly contagious and spreads through respiratory droplets. Placing the child in a negative air pressure room helps prevent the spread of the virus to others by containing the infectious particles within the room. This isolation measure is crucial in protecting both the child and other patients.
Choice B is incorrect because aspirin should not be administered to children with varicella due to the risk of Reye's syndrome. Choice C is incorrect as droplet precautions are not necessary for varicella, which primarily spreads through airborne respiratory droplets. Choice D is incorrect as Koplik spots are associated with measles, not varicella.
A nurse is caring for a group of toddlers receiving digoxin therapy. For which of the following clients should the nurse plan to hold the dose of digoxin?
- A. A toddler who has an apical pulse of 100 bpm
- B. A toddler who has a potassium level of 4.0 mEq/L (3.6 to 5.2 mEq/L)
- C. A toddler who has a digoxin level of 1.2 ng/mL (0.8 to 2.0 ng/mL)
- D. A toddler who has vomited 2 times in the last hour
Correct Answer: D
Rationale: The correct answer is D because vomiting can lead to decreased absorption of digoxin, potentially resulting in subtherapeutic levels. Holding the dose in this situation prevents giving an ineffective dose. Option A is incorrect because an apical pulse of 100 bpm is within the normal range for toddlers on digoxin. Option B is incorrect because a potassium level of 4.0 mEq/L is also within the normal range. Option C is incorrect because a digoxin level of 1.2 ng/mL falls within the therapeutic range.
A nurse is caring for a 1-month-old infant who has manifestations of severe dehydration and a prescription for parenteral fluid therapy. The guardian asks, 'What are the indications that my baby needs an IV?' Which of the following responses should the nurse make?
- A. Your baby needs an IV because she is not producing tears.
- B. Your baby needs an IV because her heart rate is decreased.
- C. Your baby needs an IV because she is breathing slower than normal.
- D. Your baby needs an IV because her fontanels are bulging.
Correct Answer: A
Rationale: The correct response is A: Your baby needs an IV because she is not producing tears. In infants, the inability to produce tears is a sign of severe dehydration, indicating a deficit in body fluids. Tears are composed of water and electrolytes, and the absence of tears suggests a significant fluid imbalance. This makes it crucial to administer parenteral fluid therapy via an IV to restore hydration levels.
Choices B, C, and D are incorrect because they do not directly correlate with the need for IV fluid therapy in this scenario. A decreased heart rate, slower breathing, and bulging fontanels may be signs of distress or other issues but do not specifically indicate the need for immediate IV fluid administration due to dehydration. Therefore, option A is the most appropriate and relevant response given the infant's presentation of severe dehydration.