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A nurse is caring for a preschooler who has diabetes mellitus and is pale, diaphoretic, and irritable. The child's blood glucose level is 52 mg/dL. Which of the following actions should the nurse take first?
- A. Give 1 tsp of peanut butter to the child.
- B. Recheck the child's blood glucose level.
- C. Administer 1 tbsp of sugar to the child.
- D. Document the incident in the child's record.
Correct Answer: C
Rationale: Administering sugar treats hypoglycemia quickly in a conscious child. Peanut butter is slow-acting, rechecking delays treatment, and documentation follows intervention.
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A nurse is collecting data from a 5-month-old infant who is postoperative following umbilical hernia repair. Which of the following measures should the nurse use to evaluate the infant's pain level?
- A. FLACC pain rating scale
- B. COMFORT pain rating scale
- C. FACES pain rating scale
- D. CRIES pain rating scale
Correct Answer: A
Rationale: FLACC is ideal for non-verbal infants post-surgery. COMFORT suits ICU settings, FACES is for older children, and CRIES is for neonates up to 6 months.
A nurse is reinforcing teaching about injury prevention with the parents of a toddler. Which of the following instructions should the nurse include in the teaching?
- A. Install window guards on windows.
- B. Place scatter rugs over hardwood floors.
- C. Keep doors locked.
- D. Supervise at playgrounds.
- E. Turn pot handles toward the front of the stove.
Correct Answer: A,C,D
Rationale: Window guards prevent falls, locked doors limit access to hazards, and supervision at playgrounds ensures safety. Scatter rugs increase tripping risks, and pot handles should face inward to prevent burns.
A nurse is contributing to a plan of care for a 24-month-old toddler. Which of the following actions should the nurse take?
- A. Allowing the toddler to button up their own shirt
- B. Asking the toddler questions that have 'yes' or 'no' answers
- C. Providing the toddler with opportunities to share toys with others
- D. Making sure the toddler has at least one nap during the day
Correct Answer: D
Rationale: Ensuring a nap supports rest and development. Buttoning shirts, yes/no questions, and sharing toys are beneficial but not the priority over rest for a toddler's well-being.
A nurse is collecting data from a child who recently experienced a psychomotor seizure. Which of the following findings should the nurse expect?
- A. Hyperactivity
- B. Nystagmus
- C. Apnea
- D. Amnesia
Correct Answer: D
Rationale: Amnesia is common post-psychomotor seizure. Hyperactivity, nystagmus, or apnea are not typical postictal findings.
A nurse is contributing to the plan of care for a child who has nephrotic syndrome and a prescription for corticosteroids. Which of the following interventions should the nurse recommend?
- A. Provide a low-sodium diet.
- B. Encourage increased fluid intake.
- C. Obtain urine ketone levels weekly.
- D. Administer pancreatic enzymes with each meal.
Correct Answer: A
Rationale: A low-sodium diet manages fluid retention in nephrotic syndrome. Increased fluids worsen edema, urine ketones are irrelevant, and pancreatic enzymes are not indicated.