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A nurse is caring for a child who has juvenile rheumatoid arthritis. Which of the following actions should the nurse take?
- A. Maintain night splints to the affected joint.
- B. Encourage the child to take daytime naps.
- C. Administer opioids on a schedule.
- D. Apply cool compresses for 20 min every hour.
Correct Answer: A
Rationale: Night splints help maintain joint position and function during sleep, preventing contractures and deformities. This is a common intervention in managing juvenile rheumatoid arthritis to ensure proper joint alignment and minimize pain and stiffness.
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A nurse is collecting data from an infant who has a large patent ductus arteriosus. Which of the following is clinical manifestations should the nurse expect?
- A. Cyanosis with crying
- B. Weak pulses
- C. Chronic hypoxemia
- D. Machine-like murmur
Correct Answer: D
Rationale: A characteristic feature of PDA is a continuous
A nurse is caring for a toddler who had a cast applied 2 hr ago due to multiple fractures of the right hand. Which of the following findings should the nurse report immediately to the charge nurse?
- A. The parent reports the child will not keep the arm elevated on the pillow.
- B. The fingers on the right hand have a capillary refill of 4 seconds.
- C. The fingertips of the right hand are swollen and bruised.
- D. The child is not attempting to move her right arm or fingers.
Correct Answer: B
Rationale: A capillary refill time of more than 2 seconds indicates poor perfusion which can be a sign of compartment syndrome.
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.
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.
A nurse is caring for a school-age child who has a fracture to the right femur. Which of the following findings is the nurse's priority?
- A. Capillary refill less than 2 seconds
- B. Tingling in the right foot
- C. 2+ right pedal pulse
- D. Respiratory rate 24/min
Correct Answer: B
Rationale: Tingling (paraesthesia) can be a sign of nerve damage or compromised circulation which may indicate complications such as compartment syndrome. This is a priority finding because it can lead to severe consequences if not addressed promptly.