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A nurse is caring for a school-age child who has a new plaster cast on her right arm. Which of the following actions should the nurse take?
- A. Place a warm
- B. moist heat pack on the cast.
- C. Position the casted arm in a dependent position.
- D. Move the casted arm with a firm grasp.
- E. Administer diphenhydramine to relieve itching.
Correct Answer: D
Rationale: Itching is common under a new cast and diphenhydramine can help manage this symptom without risking damage to the cast
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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. 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 is collecting data from a 1-year-old child who has Wilms' tumor. Which of the following findings should the nurse expect?
- A. Diarrhea
- B. Jaundice
- C. Swollen joints
- D. Abdominal mass
Correct Answer: D
Rationale: Wilms' tumor often presents as an asymptomatic abdominal mass.
A nurse is caring for an adolescent client who is receiving carbamazepine (Tegretol) for partial seizure disorder. Which of the following statements by the adolescent's parent is the priority for the nurse to address?
- A. He takes his medication between meals with water.
- B. He only sleeps about 5 hours each night.
- C. He seems to be getting a lot more bumps and bruises lately.
- D. He has not been eating as much lately.
Correct Answer: C
Rationale: Increased bruising can indicate thrombocytopeniaa potential side effect of carbamazepine which can lead to serious bleeding issues.
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 collecting data from an infant who hit her head when she fell off of a dressing table. The nurse should identify which of the following findings as indicating increased intracranial pressure?
- A. Brisk pupillary reaction to light
- B. Irritability
- C. Tachycardia
- D. Increased sensory response to painful stimuli
Correct Answer: B
Rationale: Irritability is a common early sign of increased ICP in infants. Changes in behaviour such as increased irritability or lethargy can indicate a neurological problemincluding increased pressure within the skull.