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A client who is postoperative immediately following a tonsillectomy
A nurse is caring for a client who is postoperative immediately following a tonsillectomy. Which of the flowing snacks should the nurse offer the client?
- A. Cranberry juice
- B. Ice-cream
- C. Hot tea
- D. Italian ice
Correct Answer: B,D
Rationale: The correct snacks to offer a client post-tonsillectomy are ice-cream and Italian ice. Ice-cream is soft, cold, and soothing, helping to reduce pain and inflammation. Italian ice is also cold and can provide relief. Cranberry juice and hot tea are acidic and may irritate the surgical site. Ice-cream and Italian ice are the best choices as they are gentle on the throat and provide comfort without causing discomfort.
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A preschool age child undergoing endotracheal suctioning
A charge nurse is observing a newly licensed nurse who is performing endotracheal suctioning for a preschool age child. Which of the following actions by the newly licensed nurse requires the charge nurse to intervene?
- A. Applying suction for 20 seconds
- B. Introducing the catheter without suction
- C. Rotating the catheter between the thumb and forefinger while suctioning
- D. Allowing the child to rest for 30 to 60 seconds between suctioning passes
Correct Answer: B
Rationale: The correct answer is B: Introducing the catheter without suction. When performing endotracheal suctioning, it is crucial to apply suction while introducing the catheter to effectively remove secretions. Introducing the catheter without suction can result in ineffective suctioning and potential harm to the child.
A: Applying suction for 20 seconds is within the recommended time frame for suctioning.
C: Rotating the catheter while suctioning helps to ensure thorough removal of secretions.
D: Allowing the child to rest between suctioning passes is important to prevent hypoxia and maintain oxygenation.
In summary, choice B is incorrect because it goes against the fundamental principle of effective suctioning, while choices A, C, and D are all appropriate actions during endotracheal suctioning for a preschool-age child.
An infant who has coarctation of the aorta
A nurse is collecting data from an infant who has coarctation of the aorta. Which of the following manifestations should the nurse expect?
- A. Machine-like murmur
- B. Severe cyanosis
- C. Decreased blood pressure in the legs
- D. Pulmonary edema
Correct Answer: C
Rationale: The correct answer is C: Decreased blood pressure in the legs. Coarctation of the aorta causes narrowing of the aorta, leading to decreased blood flow to the lower body. This results in decreased blood pressure in the legs due to reduced perfusion. A machine-like murmur (A) is typically associated with patent ductus arteriosus. Severe cyanosis (B) is more commonly seen in conditions like Tetralogy of Fallot. Pulmonary edema (D) is often seen in congestive heart failure.
A 2-month-old infant whose provider applied a Pavlik harness 1 week earlier for the treatment of developmental hip dysplasia
A nurse is reinforcing teaching with the mother of a 2-month-old infant whose provider applied a Pavlik harness 1 week earlier for the treatment of developmental hip dysplasia. Which of the following statements by the mother indicates an understanding of the teaching?
- A. I will use powders & lotion on his skin around the harness clasps.
- B. I will remove the harness daily, prior to giving the bath.
- C. I will adjust the harness straps every day.
- D. I will check my baby's skin under the straps frequently.
Correct Answer: D
Rationale: The correct answer is D: I will check my baby's skin under the straps frequently. This is because regularly checking the baby's skin under the harness straps is essential to ensure there are no signs of skin irritation or pressure sores. Failing to do so can lead to skin breakdown and complications.
Choice A is incorrect as using powders and lotions near the clasps can cause friction and increase the risk of skin irritation. Choice B is incorrect as removing the harness daily can disrupt the treatment process and should only be done as instructed by the healthcare provider. Choice C is incorrect as adjusting the harness straps without proper training can affect the effectiveness of the harness and potentially harm the baby.
A child with asthma who weighs 4.69 kg
A child with asthma has the following medication ordered: Theophylline 4 mg/kg/dose every 6 hrs. The child weighs 4.69 kg. Calculate the appropriate dose.
- A. 33.6 mg
- B. 18.7 mg
- C. 8.4 mg
- D. 19 mg
Correct Answer: B
Rationale: To calculate the appropriate dose for the child, we first need to determine the child's weight in mg: 4.69 kg x 4 mg/kg = 18.76 mg. Since the dose is rounded to the nearest tenth, the correct dose is 18.7 mg (choice B). This calculation ensures the child receives the correct amount of medication based on their weight. Choices A, C, and D are incorrect as they do not accurately reflect the calculated dose.
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.