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A toddler who has laryngotracheobronchitis
A nurse is caring for a toddler who has laryngotracheobronchitis. For which of the following findings should the nurse monitor to detect airway obstruction?
- A. Decreased stridor
- B. Increased restlessness
- C. Decreased heart rate
- D. Decreased temperature
Correct Answer: B
Rationale: The correct answer is B: Increased restlessness. Restlessness is a common sign of airway obstruction in toddlers with laryngotracheobronchitis. As the airway becomes more obstructed, the toddler may feel increasingly anxious and agitated, leading to increased restlessness. Monitoring for this sign is crucial as it indicates worsening respiratory distress and the need for prompt intervention.
Decreased stridor (choice A) is not indicative of airway obstruction in this condition, as stridor is a high-pitched sound heard on inspiration and can be present in both mild and severe cases of laryngotracheobronchitis. Decreased heart rate (choice C) and decreased temperature (choice D) are not typically associated with airway obstruction and are less relevant in this context.
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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.
An 8-year-old child who has sickle cell anemia and is recovering from a vaso-occlusive crisis
A nurse is caring for an 8-year-old child who has sickle cell anemia and is recovering from a vaso-occlusive crisis. Which of the following precautions should the nurse include in the discharge teaching?
- A. Drink eight glass of fluid daily.
- B. Maintain an updated hemophilus influence type b immunisation
- C. Avoid playground activities at school
- D. Assume postural drainage positions every 6 hrs
Correct Answer: A
Rationale: The correct answer is A: Drink eight glasses of fluid daily. This is crucial for children with sickle cell anemia to prevent dehydration, which can trigger vaso-occlusive crises. Adequate hydration helps maintain blood flow and prevent sickling of red blood cells. Maintaining an updated hemophilus influenzae type b immunization (choice B) is important for preventing infections but is not directly related to vaso-occlusive crises. Avoiding playground activities at school (choice C) is unnecessary as long as the child is careful and stays hydrated. Assuming postural drainage positions every 6 hours (choice D) is not relevant for sickle cell anemia management.
A child who is postoperative following a tonsillectomy
A nurse is collecting data from a child who is postoperative following a tonsillectomy. Which of the following is a clinical manifestation of a hemorrhage?
- A. Drooling
- B. Continuous swallowing
- C. Poor fluid intake
- D. Increased pain
Correct Answer: B
Rationale: The correct answer is B: Continuous swallowing. This is a clinical manifestation of hemorrhage post-tonsillectomy as the child may be swallowing blood. Drooling (A) is more indicative of airway obstruction. Poor fluid intake (C) is a sign of dehydration. Increased pain (D) can be expected postoperatively but is not specific to hemorrhage.
A child who is experiencing an acute asthma attack
A nurse is caring for a child who is experiencing an acute asthma attack. Which of the following medications should the nurse administer first?
- A. Methylprednisolone
- B. Albuterol
- C. Fluticasone
- D. Beclomethasone
Correct Answer: B
Rationale: The correct answer is B: Albuterol. During an acute asthma attack, bronchodilation is crucial to relieve airway constriction quickly. Albuterol is a short-acting beta-agonist that acts rapidly to relax the airway muscles, allowing for improved airflow. Methylprednisolone (A) is a corticosteroid that is used for long-term control, not for immediate relief. Fluticasone (C) and Beclomethasone (D) are inhaled corticosteroids for maintenance therapy and do not provide immediate relief during an acute attack. Administering Albuterol first is essential to address the acute symptoms and stabilize the child's condition.
A hospitalized 2-year-old child who has a tantrum when a parent leaves
A nurse is caring for a hospitalized 2-year-old child who has a tantrum when a parent leaves. Which of the following actions should the nurse take?
- A. Give the child a stuffed animal.
- B. Inform the child that her parent will be back in 2 hr.
- C. Call the parent to return to the child's room.
- D. Leave the child alone in the room for 5 min.
Correct Answer: A
Rationale: The correct answer is A: Give the child a stuffed animal. Offering the child a stuffed animal can provide comfort and a sense of security, helping to calm the child during the parent's absence. This action promotes emotional support and may help to reduce the child's anxiety.
Other choices are incorrect:
B: Informing the child about the parent's return time may not effectively address the immediate emotional distress.
C: Calling the parent back may not be feasible or necessary for every instance of separation anxiety.
D: Leaving the child alone can exacerbate feelings of fear and abandonment, potentially escalating the tantrum.