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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. 2+ right pedal pulse
- B. Tingling in the right foot
- C. Capillary refill less than 2 seconds
- D. Respiratory rate 24/min
Correct Answer: B
Rationale: A 2+ right pedal pulse indicates a normal pulse and is not a cause for immediate concern in a child with a femur fracture. Tingling in the right foot could indicate nerve damage or compromised blood flow, which can be a serious complication of a femur fracture. This should be the nurse's priority as it could lead to long-term damage if not addressed promptly. A capillary refill time of less than 2 seconds is considered normal and is not a cause for immediate concern in a child with a femur fracture. A respiratory rate of 24/min is within the normal range for a school-age child and is not a cause for immediate concern in a child with a femur fracture.
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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. Apple juice
Correct Answer: A
Rationale: An orange ice pop is a good choice because it is cold and soothing for the throat, and it is also clear liquid which is usually recommended after tonsillectomy. Cranberry juice is not the best choice because it is acidic and can cause discomfort to the surgical site. Ice cream is not recommended immediately after surgery because dairy products can increase mucus production which can lead to coughing and discomfort. Apple juice is not the best choice because it is acidic and can cause discomfort to the surgical site.
A nurse is gathering information from a 1-year-old child who has been diagnosed with Wilms' tumor. Which of the following symptoms should the nurse anticipate?
- A. Jaundice
- B. Abdominal mass
- C. Swollen joints
- D. Diarrhea
Correct Answer: B
Rationale: Jaundice, a yellowing of the skin and eyes, is not typically a symptom of Wilms' tumor. It is more commonly associated with conditions that cause liver dysfunction. An abdominal mass is one of the most common symptoms of Wilms' tumor. Parents or healthcare providers may feel a lump or swelling in the child's abdomen. Swollen joints are not a typical symptom of Wilms' tumor. They are more commonly associated with conditions that affect the joints, such as juvenile arthritis. Diarrhea is not a typical symptom of Wilms' tumor. It is more commonly a symptom of gastrointestinal illnesses.
A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority?
- A. Place a pillow under the child's head.
- B. Remove the child's eyeglasses.
- C. Time the seizure.
- D. Move the child into a side-lying position.
Correct Answer: D
Rationale: While placing a pillow under the child's head might seem like a good idea, it's actually not recommended during a seizure. The child's movements could be unpredictable, and a pillow could potentially cause suffocation. Removing the child's eyeglasses is a good idea, but it's not the first thing you should do. The child's safety is the top priority, and eyeglasses can be removed once the child is safe. Timing the seizure is important for medical professionals to know, but it's not the first action to take. The child's immediate safety is the priority. Moving the child into a side-lying position is the priority. This position helps keep the airway clear and allows any vomit to exit the mouth, reducing the risk of choking.
A nurse is planning to monitor a client for dehydration following several episodes of vomiting and an increase in the client's temperature. Which of the following findings should the nurse identify as an indication that the client is dehydrated?
- A. Urine specific gravity 1.034.
- B. Bounding pulse.
- C. BP 46/94 mm Hg.
- D. Distended neck veins.
Correct Answer: A
Rationale: A urine specific gravity of 1.034 is higher than the normal range (1.002-1.030), indicating that the urine is more concentrated due to a lack of hydration. A bounding pulse is not typically associated with dehydration. Dehydration more commonly results in a weak, rapid pulse. A blood pressure reading of 46/94 mm Hg is not indicative of dehydration. Dehydration often leads to low blood pressure. Distended neck veins are not a typical sign of dehydration. Dehydration can lead to decreased blood volume, which would not cause distension of the neck veins.
A child weighs 6 lbs and is to receive Ampicillin 50 mg/kg/24 hrs and then it's divided into q hr doses. How many mg will he receive with each dose?
- A. 90 mg
- B. 60 mg
- C. 36 mg
- D. 290 mg
Correct Answer: C
Rationale: Step 1: Convert the child's weight from lbs to kg. Since 1 lb is approximately 0.45 kg, a child who weighs 6 lbs weighs approximately 2.72 kg (6 lbs × 0.45 =2.72 kg). Step 2: Calculate the total daily dose of Ampicillin. The total daily dose is 50 mg/kg/day, so for a child who weighs 2.72 kg, the total daily dose would be approximately 136 mg (50 mg/kg/day × 2.72 kg = 136 mg/day). Step 3: Since the total daily dose is divided into q hr doses (4 doses per day), each dose would be approximately 34 mg (136 mg/day ÷ 4 doses/day = 34 mg/dose). So, the child will receive approximately 34 mg of Ampicillin with each dose.