Nokea
A nurse is assisting in the admission of a 9-month-old infant who has gastroenteritis with vomiting and diarrhea. Which of the following findings is the nurse's priority?
- A. Skin turgor
- B. Potassium level
- C. Capillary refill
- D. Heart rate
Correct Answer: D
Rationale: The elevated heart rate (tachycardia) at 182/min indicates increased cardiac workload, likely due to dehydration from gastroenteritis, requiring immediate attention. While skin turgor, potassium levels, and capillary refill are important, tachycardia is the priority to stabilize the infant.
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A nurse is reinforcing teaching with an adolescent client who has a prescription for lisinopril. Which of the following foods should the nurse instruct the client to avoid?
- A. Foods high in fiber
- B. High-potassium foods
- C. Foods high in vitamin K
- D. Dairy products
Correct Answer: B
Rationale: Lisinopril can raise potassium levels, so avoiding high-potassium foods prevents hyperkalemia. Fiber, vitamin K, and dairy are not contraindicated.
A nurse is reinforcing preoperative teaching with an adolescent client who is scheduled for a surgical repair of scoliosis. Which of the following statements by the client indicates effectiveness of the teaching?
- A. I will not be able to walk before I go home.
- B. I will begin range-of-motion exercises on the first postoperative day.
- C. I will be discharged in 3 days.
- D. I will be fitted for my brace the day of discharge.
Correct Answer: B
Rationale: Starting range-of-motion exercises on the first postoperative day shows understanding of early mobilization. Misconceptions about walking, discharge timing, or brace fitting do not reflect accurate teaching.
A nurse is reinforcing car seat safety instructions with the parents of a 15-month-old toddler. Which of the following statements by the parents indicates an understanding of the teaching?
- A. I should place my child in a forward-facing car seat to ensure safety.
- B. I should place my child in the front seat in a rear-facing car seat.
- C. I should continue to use a booster seat until my child is 5 years old.
- D. I should place my child in a rear-facing car seat until age 2.
Correct Answer: D
Rationale: Rear-facing car seats until age 2 protect the child's head, neck, and spine. Forward-facing too early, front-seat placement, or premature booster use increase injury risk.
A nurse is assisting with the care of a child who is in status asthmaticus. Which of the following medications should the nurse administer first?
- A. Heliox via inhalation
- B. Albuterol via nebulizer
- C. Prednisone by mouth
- D. 0.9% sodium chloride via IV bolus
Correct Answer: B
Rationale: Albuterol rapidly relieves bronchospasm in status asthmaticus. Heliox, prednisone, and saline are secondary or not indicated as first-line treatments.
A nurse is reinforcing teaching with the parent of a child who has diabetes mellitus. The parent asks the nurse how to minimize the child's pain when monitoring blood glucose levels. Which of the following statements by the parent indicates an understanding of the teaching?
- A. My child should use their index finger to obtain blood samples.
- B. My child should hold their finger under warm water before obtaining a sample.
- C. My child should puncture the center of their finger pad when obtaining a sample.
- D. My child should hold their finger against a table when obtaining a sample.
Correct Answer: B
Rationale: Warm water increases blood flow, reducing pain during glucose monitoring. Index finger use, central punctures, or table pressure do not specifically minimize discomfort.