Nokea
A nurse is caring for a child with acute glomerulonephritis. The child has edema, hypertension, and gross hematuria. Which of the following is the most appropriate nursing intervention?
- A. Monitor the oxygen saturation every 4 hr.
- B. Teach the parents dietary restrictions regarding protein.
- C. Weigh the child daily and record intake and output.
- D. Counsel the parents about the need for follow-up.
Correct Answer: C
Rationale: The correct answer is C: Weigh the child daily and record intake and output. This intervention is crucial in monitoring fluid balance and kidney function in a child with acute glomerulonephritis. Daily weights help assess for fluid retention, while intake and output measurements help evaluate kidney function. Edema, hypertension, and gross hematuria are key symptoms of this condition, indicating the need for close monitoring.
Choice A is incorrect because monitoring oxygen saturation is not directly related to the management of acute glomerulonephritis. Choice B is also incorrect as dietary restrictions regarding protein are not the priority in this situation. Choice D is incorrect as counseling about follow-up is important but not the most immediate intervention needed.
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A woman at 42 weeks gestation enters the hospital for induction of labor. Since the infant is postterm, which complications should the nurse anticipate when planning for the delivery?
- A. Cephalopelvic disproportion and hypothermia
- B. Asphyxia and meconium aspiration
- C. Intraventricular hemorrhage and dry,cracked skin
- D. Hyperbilirubinemia and hypocalcemia
Correct Answer: B
Rationale: The correct answer is B: Asphyxia and meconium aspiration. At 42 weeks gestation, the risk of perinatal asphyxia increases due to decreased placental function. Meconium aspiration can occur if the fetus passes stool in utero, leading to respiratory distress. The other choices are not directly related to postterm pregnancy complications. Cephalopelvic disproportion and hypothermia (Choice A) are not specific to postterm pregnancy. Intraventricular hemorrhage and dry, cracked skin (Choice C) are not commonly associated with postterm pregnancies. Hyperbilirubinemia and hypocalcemia (Choice D) are more likely to occur after birth and are not directly related to being postterm.
During the first twelve hours following a normal vaginal delivery, the client voids 2,000 mL of urine. How should the nurse interpret this finding?
- A. Urinary tract infection
- B. High output renal failure
- C. Excessive use of IV fluids during delivery
- D. Normal diuresis after delivery
Correct Answer: D
Rationale: The correct interpretation is D: Normal diuresis after delivery. After childbirth, diuresis is common due to the body eliminating excess fluid retained during pregnancy. This process helps reduce swelling and aids in returning to pre-pregnancy state. Voiding 2,000 mL in the first twelve hours is within the expected range for postpartum diuresis. Choices A, B, and C are incorrect as they do not align with the typical physiologic response to childbirth. Urinary tract infection and high output renal failure would present with other symptoms, while excessive IV fluid use would not explain the timing or volume of urine output.
During an outpatient clinic visit, a 13-year-old client is diagnosed with infectious mononucleosis. The nurse should expect which of the following to be included in the client's plan of care?
- A. Take acetaminophen (Tylenol) with codeine as prescribed for pain.
- B. Encourage gargling with warm water to alleviate pain.
- C. Start a short course of ampicillin.
- D. Encourage social activity to prevent depression.
Correct Answer: B
Rationale: The correct answer is B: Encourage gargling with warm water to alleviate pain. Gargling with warm water can help soothe a sore throat, a common symptom of infectious mononucleosis. Acetaminophen with codeine (A) is not typically recommended for mononucleosis pain management in children due to the risk of respiratory depression. Starting a short course of ampicillin (C) is contraindicated in mononucleosis as it can cause a rash. Encouraging social activity (D) may not be appropriate as the client may need rest to recover.
The dosage of a pediatric medication is 120mg/kg/day to be given t.i.d. The patient weighs 12 pounds. What is the correct dose for the nurse to administer?
- A. 120 mg
- B. 480 mg
- C. 218 mg
- D. 651 mg
Correct Answer: C
Rationale: The patient weighs twelve pounds, which converts to kilograms by dividing 12 by 2.2 (1 kg = 2.2 lb.). In this example, the child's weight converts to 5.4 kg. The daily dose of 120 mg is given t.i.d: each individual dose is 40 mg/kg. Then multiply the weight in kilograms by the individual dose (40mg). The individual dose is 218 mg.
A nurse is reviewing discharge instructions with the parent of an infant who has acute laryngotracheobronchitis (croup).
- A. "I will give my child the corticosteroids prescribed by the doctor."'
- B. "I will clear the child's nasal passages with a bulb syringe to aid in breathing."'
- C. "I will place a dehumidifier in my child's room."'
- D. "I will encourage my child to take plenty of fluids over the next several days."'
Correct Answer: C
Rationale: The correct answer is C: "I will place a dehumidifier in my child's room."
Rationale:
1. Acute laryngotracheobronchitis (croup) is a condition that causes swelling in the upper airway, leading to breathing difficulties.
2. Placing a dehumidifier in the child's room can help maintain optimal humidity levels, which can soothe the inflamed airways and ease breathing.
3. Moist air from the dehumidifier can help reduce coughing and throat irritation, providing comfort to the child.
4. This intervention is specific to managing the symptoms of croup and can support the child's recovery.
Summary:
- Choice A: Corticosteroids are prescribed by the doctor for croup, but it is not the parent's responsibility to administer them.
- Choice B: Clearing nasal passages with a bulb syringe is not directly related to managing croup symptoms.
- Choice D: Encouraging fluids