Nokea
A nurse is caring for a client who is postoperative immediately following a tonsillectomy. Which of the following snacks should the nurse offer the client?
- A. Lime ice pop
- B. Cranberry juice
- C. Ice cream
- D. Hot tea
Correct Answer: A
Rationale: A lime ice pop is a good option because it is cold soothing and less likely to irritate the throat or cause bleeding. The cold temperature can help reduce swelling and provide comfort.
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A nurse is preparing a 4-year-old child for discharge following a bilateral myringotomy with tympanostomy tube placement. The mother asks what to do if the tubes fall out. The nurse should give the parent which of the following instructions?
- A. Gently reinsert the tubes.
- B. Call the health care clinic to report that the tubes have fallen out.
- C. Reassure the mother that the tubes will not fall out.
- D. Take the child to an emergency department.
Correct Answer: B
Rationale: The healthcare provider needs to be informed to assess if new tubes are necessary.
A nurse is reviewing the medical record of an adolescent and notes a calcium level of 11.4 mEq/L. Which of the following findings should the nurse expect?
- A. Tachycardia
- B. Diarrhea
- C. Positive Chvostek's sign
- D. Muscle hypotonicity
Correct Answer: D
Rationale: Hypercalcemia can lead to muscle weakness and hypotonicity due to its effects on nerve and muscle function.
A nurse is preparing to administer amoxicillin 350 mg PO. The amount available is amoxicillin oral solution 250 mg/5 mL. How many ml. should the nurse administer? (Round the answer to the nearest tenth/whole number. Use a leading zero if it applies. Do not use a trailing zero.)
- A. 7 mL
- B. 6 mL
- C. 8 mL
- D. 5 mL
Correct Answer: 7
Rationale: Formula: Volume to administer=Desired dose/Available dose ×Volume available. Calculation: 350 mg/250 mg × 5 mL=7 mL.
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.
A nurse working at a clinic speaks on the telephone with a parent of a 2-month-old infant. The parent tells the nurse that the infant has projectile vomiting followed by hunger after meals. Which of the following responses by the nurse is appropriate?
- A. Bring your infant into the clinic today to be seen.
- B. You might want to try switching to a different formula.
- C. Give your infant an oral rehydration solution.
- D. Burp your child more frequently during feedings.
Correct Answer: A
Rationale: Projectile vomiting can be a sign of pyloric stenosis a condition that requires prompt medical evaluation.