Nokea
A nurse is caring for a preschooler immediately following the application of a long-leg plaster cast due to a fracture. Which of the following actions is the nurse's priority?
- A. Monitor capillary refill of the casted extremity.
- B. Use the palms of the hands when supporting the cast.
- C. Examine the skin at the cast edges.
- D. Instruct the child not to put anything inside the cast.
Correct Answer: A
Rationale: Monitoring capillary refill is critical to assess circulation and detect complications like compartment syndrome post-cast application. Supporting the cast, checking skin, and instructing the child are important but secondary to ensuring circulation.
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A nurse is reinforcing teaching with the parent of a school-age child who is undergoing testing for acute lymphoid leukemia (ALL). The nurse should inform the parent that the child will undergo which of the following tests to confirm the diagnosis?
- A. Spinal fluid analysis
- B. Complete blood count
- C. Bone marrow biopsy
- D. Bleeding time
Correct Answer: C
Rationale: Bone marrow biopsy is the definitive test to confirm ALL by examining marrow for abnormal cells. Spinal fluid analysis and CBC may support diagnosis but are not confirmatory. Bleeding time assesses platelet function, not leukemia.
A nurse is reinforcing teaching with the guardian of a 1-month-old infant who has a cleft lip and is bottle fed. Which of the following statements the guardian indicates that the teaching was effective?
- A. I will wait to burp my baby until after the feeding is finished.
- B. I will use a narrow-based nipple to feed my baby.
- C. I will hold my baby in an upright position during feedings.
- D. I will allow my baby's cheeks to remain relaxed during feeding.
Correct Answer: C
Rationale: Upright positioning prevents milk entering nasal passages in cleft lip infants. Delaying burping, narrow nipples, or relaxed cheeks are less effective.
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 caring for a 13-month-old toddler who has a prescription for a urinary catheter. Which of the following urinary catheters should the nurse use?
- A. 5 French
- B. 12 French
- C. 10 French
- D. 14 French
Correct Answer: A
Rationale: A 5 French catheter is appropriate for a toddler to minimize urethral trauma. Larger sizes (10, 12, 14 French) risk discomfort or injury.
A nurse is caring for a toddler who has a respiratory illness and a temperature of 39.3° C (102.7° F). Which of the following actions should the nurse take to reduce the toddler's temperature?
- A. Give the toddler a tepid bath.
- B. Administer an aspirin suppository.
- C. Remove the toddler's extra clothing.
- D. Apply a cooling blanket.
Correct Answer: C
Rationale: Removing extra clothing allows heat loss safely. Tepid baths risk shivering, aspirin risks Reye's syndrome, and cooling blankets are for severe cases.