Nokea
A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take?
- A. Loosen restrictive clothing.
- B. Hyperextend the child's neck.
- C. Time the seizure episode.
- D. Place the child in a side-lying position.
- E. Restrain the child.
Correct Answer: A,C,D
Rationale: Loosening clothing, timing the seizure, and side-lying position ensure safety and documentation. Hyperextending the neck risks injury, and restraining is unsafe.
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A nurse is caring for an infant who has a cleft palate and is having trouble bottle feeding. Which of the following actions should the nurse take?
- A. Select a bottle with a one-way flow valve.
- B. Choose a bottle with a narrow nipple.
- C. Burp the infant every 90 ml (3 oz).
- D. Use the football hold when feeding the child.
Correct Answer: A
Rationale: A one-way flow valve bottle controls milk flow, aiding infants with cleft palate. Narrow nipples, frequent burping, or football hold are less specific to feeding challenges.
A nurse is assisting with the care of an infant who requires emergency surgery and whose parent is an emancipated adolescent. Which of the following people can sign the informed consent form for the procedure?
- A. The parent of the adolescent parent
- B. The adolescent parent
- C. The infant's provider
- D. The adult sibling of the adolescent parent
Correct Answer: B
Rationale: An emancipated adolescent parent has legal authority to consent for their child's procedure. Others lack this authority unless legally designated.
A nurse is preparing to perform a heel stick on an infant. Which of the following actions should the nurse take?
- A. Use an automated lancet device to puncture the heel.
- B. Apply limb restraints to the infant.
- C. Puncture the heel at the inner aspect of the heel.
- D. Cleanse the area with povidone iodine.
Correct Answer: A
Rationale: An automated lancet device ensures a controlled puncture, minimizing discomfort. Restraints are unnecessary, the inner heel is not the correct site, and povidone iodine is not typically used for heel sticks.
A nurse is preparing to percuss an adolescent's chest and abdomen. Which of the following areas should the nurse expect to hear a dull sound?
- A. This region of the chest is expected to be resonant on percussion because of the air in the lung.
- B. The right upper quadrant of the abdomen is usually dull on percussion because of the underlying liver.
- C. This site is tympanic because of the gas in the intestines.
Correct Answer: B
Rationale: The right upper quadrant is dull due to the liver. The chest is resonant, and intestines are tympanic.
A nurse is reinforcing discharge teaching about preventing infections with the parent of a child who is receiving chemotherapy and has a platelet count of 100,000/mm3. Which of the following statements by the parent indicates an understanding of the teaching?
- A. I will take my child's rectal temperature daily to ensure the most accurate reading.
- B. I will make sure my child receives the MMR vaccine by the end of the week.
- C. I will take my child to the park to ride her new bike.
- D. I will inspect the inside of my child's mouth for sores every day.
Correct Answer: D
Rationale: Inspecting the mouth for sores detects mucositis early, reducing infection risk. Rectal temperatures, live vaccines like MMR, and park visits increase infection risk during chemotherapy.