Nokea
A nurse is calculating the output of an infant admitted who has dehydration. When weighing the diaper, the nurse should equate 1 g of wet diaper weight to which of the following amounts of urine?
- A. 30 mL
- B. 1 mL
- C. 15 mL
- D. 5 mL
Correct Answer: B
Rationale: It is a standard practice to equate 1 gram of wet diaper weight to 1 mL of urine providing an accurate measure for fluid balance in infants.
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A nurse is assisting with the admission of a child who has pertussis. Which of the following actions should the nurse take?
- A. Initiate droplet precautions.
- B. Initiate a protective environment.
- C. Initiate contact precautions.
- D. Initiate airborne precautions.
Correct Answer: A
Rationale: Pertussis (whooping cough) is transmitted via respiratory droplets.
A nurse is caring for a toddler who is scheduled to have a lumbar puncture. Which of the following actions should the nurse take?
- A. Restrain the toddler for 1 hr after the procedure.
- B. Place the toddler in a side-lying
- C. knee-chest position.
- D. Ask another nurse to assist with holding the toddler in a prone position.
- E. Swaddle the toddler in a warm blanket.
Correct Answer: B
Rationale: This position helps to open the spaces between vertebrae, facilitating the lumbar puncture.
A nurse is caring for a 2-month-old infant who is postoperative following repair of a cleft lip and palate. The surgeon prescribes restraints. The nurse should apply which of the following types of restraints to the infant?
- A. Wrist
- B. Mummy
- C. Elbow
- D. Jacket
Correct Answer: C
Rationale: Elbow restraints prevent the infant from bending their arms keeping them from touching their face and disrupting the surgical site.
A nurse on a pediatric unit is receiving a report from an assistive personnel (AP). Which of the following clients should the nurse plan to visit first?
- A. A 4-year-old preschooler who has status asthmaticus and a pulse oximetry of 95%
- B. A 1-year-old infant who has roseola and a temperature of 39°C (102.2°F)
- C. A 7-year-old child who has diabetes insipidus and a urine specific gravity of 1.002
- D. A 10-year-old child who has sickle cell anemia and a pain rating of 6 on a 0 to 10 scale
Correct Answer: C
Rationale: A urine specific gravity of 1.002 indicates very dilute urine
A nurse is caring for a 4-year-old child who is postoperative following abdominal surgery. Which of the following statements should the nurse make to encourage the child to take deep breaths?
- A. This will not be painful, just a little uncomfortable.
- B. Let's play a game of blowing cotton balls across your table.
- C. Do you want to take deep breaths for me now?
- D. You can't go to the playroom until you finish doing your deep breathing.
Correct Answer: B
Rationale: This makes deep breathing fun and engaging for the child encouraging them to participate.