Nokea
A nurse is assisting with the care of a school-age child who has respiratory failure due to pneumonia. Which of the following positions should the nurse encourage to allow maximal lung expansion?
- A. Supine
- B. Prone
- C. Upright
- D. Side-lying
Correct Answer: C
Rationale: Sitting upright or in a high Fowler's position is optimal for lung expansion.
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A nurse is reinforcing discharge teaching with the parent of a child who has a new diagnosis of diabetes mellitus. Which of the following statements by the parent requires a clarification of the teaching?
- A. Sweating can occur with hypoglycemia.
- B. My son might have nausea and vomiting with hypoglycemia.
- C. My son might complain of feeling shaky when he has a low blood glucose level.
- D. The onset of low blood glucose usually occurs rapidly.
Correct Answer: B
Rationale: Nausea and vomiting are typically associated with hyperglycemia and diabetic ketoacidosis (DKA) not hypoglycaemia. Hypoglycaemia usually presents with symptoms like sweating shakiness confusion and hunger.
A nurse is caring for a child following an open reduction and internal fixation of a fractured femur and application of a cast. The cast has a window cut in it for viewing of the incision. Which of the following actions should the nurse take first?
- A. Remove the window and view the incision.
- B. Medicate the client for pain.
- C. Perform neurovascular checks of the affected extremity.
- D. Turn the client so the cast will dry on all sides.
Correct Answer: C
Rationale: Performing neurovascular checks is the highest priority to ensure that circulation sensation and movement are intact.
A nurse is preparing to administer ear drops to a 2-year-old toddler who has an ear infection and a small amount of purulent drainage visible around the ear. Which of the following techniques should the nurse use when instilling the medication?
- A. Firmly push a cotton ball into the ear canal after instilling drops.
- B. Pull the child's ear auricle upward and outward just before instilling drops.
- C. Apply clean gloves and clean the outer ear prior to instilling drops.
- D. Warm the medication container for 10 seconds in a microwave oven prior to installation.
Correct Answer: C
Rationale: Applying clean gloves and cleaning the outer ear is essential for preventing infection and ensuring that the medication is administered properly. This is a standard procedure to maintain hygiene.
A nurse is reinforcing teaching with an assistive personnel (AP) about counting the respiratory rate for a 1-month-old infant. Which of the following statements by the AP indicates an understanding of the teaching?
- A. I will immediately report irregular respirations.
- B. I will immediately report a respiratory rate of 28.
- C. I will count the baby's respirations for 30 seconds and multiply by two.
- D. I will count the baby's respirations by observing abdominal movements.
Correct Answer: D
Rationale: In infants respiration is primarily diaphragmatic making abdominal movements a reliable indicator of respiratory rate.
A nurse is attempting to obtain information from a child who is hearing impaired. Which of the following actions should the nurse take?
- A. Stand above the child's eye level when speaking.
- B. Talk directly into the child's impaired ear.
- C. Speak loudly to the child.
- D. Speak slowly while facing the child.
Correct Answer: D
Rationale: Speaking slowly and facing the child ensures that they can read lips and facial expressions.