Nokea
A nurse is assisting with the admission of a 2-year-old toddler who has acute gastroenteritis. Which of the following actions should the nurse take first?
- A. Determine if the toddler is voiding.
- B. Request evaluation of the toddler's serum electrolytes.
- C. Initiate isotonic fluids with 20 mEq/L potassium chloride.
- D. Collect a stool sample from the toddler.
Correct Answer: A
Rationale: Assessing urine output is crucial for determining the child's hydration status. Voiding is an important indicator of kidney function and fluid balance.
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A nurse in a clinic is preparing to administer pre-kindergarten vaccines to a 5-year-old child whose medical record indicates that his Immunizations are up to date. Which of the following vaccines should the nurse plan to administer?
- A. Hepatitis B (HBV)
- B. Measles
- C. mumps
- D. and rubella (MMR)
- E. Haemophilus influenzae type B (Hib)
- F. Pneumococcal conjugate vaccine (PCV)
Correct Answer: B
Rationale: The MMR vaccine is part of the pre-kindergarten immunization schedule.
An adolescent was recently diagnosed with acne vulgaris and was prescribed tetracycline. Which of the following statements indicates that the client requires further education?
- A. I'll take this medication at least an hour before I eat a meal
- B. I'll take this medication with a full glass of milk
- C. I'll take this medication with a full glass of water on an empty stomach
- D. I'll stay out of direct sunlight while taking this medication
Correct Answer: B
Rationale: Tetracycline should not be taken with dairy products including milk because calcium in dairy can bind to the antibiotic and significantly reduce its absorption.
A nurse is caring for a school-age child who has a new plaster cast on her right arm. Which of the following actions should the nurse take?
- A. Place a warm
- B. moist heat pack on the cast.
- C. Position the casted arm in a dependent position.
- D. Move the casted arm with a firm grasp.
- E. Administer diphenhydramine to relieve itching.
Correct Answer: D
Rationale: Itching is common under a new cast and diphenhydramine can help manage this symptom without risking damage to the cast
A nurse is contributing to the plan of care for a school-age child who has moderate partial-thickness burns on both lower extremities. Which of the following interventions should the nurse include?
- A. Maintain medical asepsis during dressing changes.
- B. Administer pain medication 30 min to 1 hour before physical therapy.
- C. Allow the child to set her own schedule for care.
- D. Provide low-calorie snacks.
Correct Answer: B
Rationale: Pain management is crucial to facilitate participation in physical therapy and improve outcomes.
A nurse is caring for an Infant who has spina bifida. Which of the following actions should the nurse take?
- A. Perform range-of-motion (ROM) exercises to the infant's hips.
- B. Place the infant in a prone position.
- C. Feed the infant through an NG tube.
- D. Cover the infant's lesion with a dry cloth.
Correct Answer: B
Rationale: This helps prevent pressure on the spina bifida lesion and minimizes the risk of injury or infection.