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A child who is postoperative following the insertion of a ventriculoperitoneal shunt
A nurse is caring for a child who is postoperative following the insertion of a ventriculoperitoneal shunt. The nurse should place the child in which of the following positions?
- A. A 45 degree head elevation
- B. On the nonoperative side
- C. Prone
- D. Supine
Correct Answer: D
Rationale: The correct answer is D: Supine. Placing the child in a supine position promotes proper drainage and prevents obstruction of the ventriculoperitoneal shunt. Supine position helps maintain a neutral head position, reducing the risk of complications. A 45-degree head elevation (choice A) can increase intracranial pressure, which is contraindicated in this case. Placing the child on the nonoperative side (choice B) or prone (choice C) can potentially cause kinking or obstruction of the shunt tubing.
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A child who has spina bifida occulta
A nurse is collecting data from a child who has spina bifida occulta. Which of the following findings should the nurse expect?
- A. Flaccid paralysis of lower extremities
- B. Hip dislocation
- C. Hydrocephalus
- D. Dimple in sacral area
Correct Answer: D
Rationale: The correct answer is D: Dimple in sacral area. In spina bifida occulta, there is a small gap in the spine but no protrusion of the spinal cord or meninges. A dimple in the sacral area is a common physical finding. Flaccid paralysis of lower extremities (A) is more characteristic of myelomeningocele, not occulta. Hip dislocation (B) is not typically associated with spina bifida occulta. Hydrocephalus (C) is more commonly seen with myelomeningocele as well. The presence of a dimple in the sacral area is a key indicator of spina bifida occulta due to the incomplete closure of the spinal column.
A dehydrated child who weighs 10 kg
A dehydrated child has intravenous aid therapy ordered. The child weighs 10 kg. Physician ordered Lactated Ringer's solution 40 ml/kg over 4 hours How many miles per hour will this child receive?
- A. 300ml/hour
- B. 100 mL/hour
- C. 50mL/hour
- D. 200 ml/hour
Correct Answer: B
Rationale: The correct answer is B: 100 mL/hour. To calculate the IV rate, we first multiply the weight of the child (10 kg) by the ordered rate (40 ml/kg) which gives us 400 ml over 4 hours. To convert this to ml per hour, we divide 400 ml by 4 hours, resulting in 100 ml/hour. This calculation ensures the child receives the correct amount of fluid over the specified time frame. Other choices are incorrect because they do not follow the correct calculation method or do not align with the physician's order.
An adolescent who is having a sickle cell crisis
A nurse is caring for an adolescent who is having a sickle cell crisis. Which of the following nursing actions should the nurse take?
- A. withhold opioids to avoid dependence
- B. Assist RN with administering a blood transfusion
- C. Initiate a 2 L/day fluid restriction
- D. Encourage exercise
Correct Answer: B
Rationale: The correct answer is B: Assist RN with administering a blood transfusion. During a sickle cell crisis, blood transfusions can help improve oxygen delivery to tissues by increasing the number of normal red blood cells. This can help alleviate symptoms and prevent complications. Withholding opioids (choice A) can lead to inadequate pain management. Initiation of fluid restriction (choice C) is inappropriate as hydration is crucial during a sickle cell crisis. Encouraging exercise (choice D) can worsen the crisis by increasing the risk of vaso-occlusive events.
A child who has cystic fibrosis
A nurse is reinforcing discharge instructions with a parent of a child who has cystic fibrosis. Which of the following statements by the parent indicates an understanding of the teaching?
- A. I will restrict the amount of salt in my child's meals.
- B. I will put my child in daycare to ensure that she socializes with other children.
- C. I will make sure my child washes her hands before eating.
- D. I will provide low-fat meals for my child.
Correct Answer: C
Rationale: The correct answer is C: "I will make sure my child washes her hands before eating." This statement indicates an understanding of the teaching because proper handwashing is crucial in preventing infections in individuals with cystic fibrosis who are more susceptible to respiratory infections. By washing hands before eating, the child can reduce the risk of exposure to harmful pathogens.
Choice A is incorrect because restricting salt intake is not a priority in managing cystic fibrosis. Choice B is incorrect as the focus should be on hygiene and health rather than socialization. Choice D is incorrect as children with cystic fibrosis actually require a higher calorie and fat intake.
A school-age child who has respiratory failure due to pneumonia
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. Upright
- B. Supine
- C. Prone
- D. Side-lying
Correct Answer: A
Rationale: The correct answer is A: Upright. In an upright position, gravity helps to maximize lung expansion by allowing the diaphragm to descend fully. This position promotes better ventilation and oxygenation by reducing the pressure on the lungs. Supine (B), prone (C), and side-lying (D) positions can limit lung expansion and compromise breathing mechanics. These positions may cause the abdominal contents to compress the lungs, reducing their ability to expand fully. Therefore, encouraging the child to sit upright will optimize lung function and promote effective gas exchange.