Nokea
A nurse is assisting with the care of an infant who is postoperative following surgical repair of a cleft lip and palate. Which of the following action should the nurse plan to take?
- A. Gently rub betadine on the infant's incisions to prevent infection.
- B. Place the infant in a prone position for 1 hr to facilitate drainage of secretions.
- C. Weigh the infant once each day using the same scale.
- D. Suction the infant's nose and mouth using an in-line device on the lowest setting.
Correct Answer: C
Rationale: Daily weighing monitors fluid status post-surgery. Betadine risks irritation, prone positioning may obstruct airways, and suctioning could harm the surgical site.
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A nurse is reinforcing teaching with the parent of a 15-month-old toddler about nutritional guidelines. Which of the following statements by the parent indicates an understanding of the teaching?
- A. My child will be constipated if they drink more than 6 ounces of juice a day.
- B. My child's intake of calcium should average 500 milligrams every day.
- C. My child should consume 1,500 to 1,800 calories each day by the time they turn 2.
- D. My child's appetite will increase suddenly when they turn 18 months old.
Correct Answer: B
Rationale: A 15-month-old toddler needs about 500 milligrams of calcium per day to support bone growth and development. Excessive juice does not cause constipation but can reduce appetite for other foods. Toddlers need approximately 1,000 to 1,300 calories per day, so 1,500-1,800 calories is excessive. There is no specific age-related sudden appetite increase at 18 months.
A nurse is caring for an adolescent who reports manifestations of an STI. Which of the following actions should the nurse take?
- A. Request that the adolescent sign a consent for treatment form prior to performing STI screening.
- B. Instruct the adolescent that a guardian must be present to provide consent for STI screening.
- C. Plan to notify the adolescent's guardian if the STI screening comes back positive.
- D. Obtain phone consent from the guardian of the adolescent prior to performing STI screening.
Correct Answer: A
Rationale: Adolescents can consent to STI screening in many jurisdictions, respecting their privacy. Guardian involvement may deter care, and notification breaches confidentiality unless required.
A nurse is reinforcing teaching with an adolescent client who has oral candidiasis and a new prescription for clotrimazole troche. Which of the following instructions should the nurse include in the teaching?
- A. Place the medication in the refrigerator after each use.
- B. Be sure to let the troche dissolve in your mouth for 15 minutes.
- C. Crush the troche before mixing it with applesauce.
- D. Stop the medication if white patches appear in your mouth.
Correct Answer: B
Rationale: Dissolving the troche slowly maximizes effectiveness. Refrigeration isn't needed, crushing alters delivery, and white patches indicate ongoing infection, not a reason to stop.
A nurse is reinforcing teaching with the guardian of a 1-month-old infant who has a cleft lip and is bottle fed. Which of the following statements the guardian indicates that the teaching was effective?
- A. I will wait to burp my baby until after the feeding is finished.
- B. I will use a narrow-based nipple to feed my baby.
- C. I will hold my baby in an upright position during feedings.
- D. I will allow my baby's cheeks to remain relaxed during feeding.
Correct Answer: C
Rationale: Upright positioning prevents milk entering nasal passages in cleft lip infants. Delaying burping, narrow nipples, or relaxed cheeks are less effective.
A nurse is obtaining a sputum sample from a school-age child. Which of the following actions should the nurse take?
- A. Ask the child to cough deeply.
- B. Ask the child to clear their throat.
- C. Use wall suction to obtain the sample from the child's throat.
- D. Use a bulb syringe to obtain sputum from the child's mouth.
Correct Answer: A
Rationale: Asking the child to cough deeply helps obtain a sputum sample from the lower respiratory tract. Clearing the throat, wall suction, or bulb syringe are less effective or inappropriate methods.