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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.
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A child who has iron deficiency anemia
A nurse in a pediatric clinic in caring for a child who has iron deficiency anemia and is to start taking ferrous sulfate syrup. Which of the following Instructions should the nurse give the parent?
- A. Administer the medication at meal time
- B. Administer the medication at bedtime.
- C. Offer the medication through a straw
- D. Dilute the medication with 240 mi. (Bar) of milk
Correct Answer: C
Rationale: The correct answer is C: Offer the medication through a straw. This is because iron supplements can stain teeth, and using a straw can help minimize direct contact with the teeth, reducing the risk of staining. Administering the medication at mealtime (choice A) may cause gastrointestinal upset, and administering it at bedtime (choice B) may increase the risk of staining teeth during sleep. Diluting the medication with milk (choice D) is not recommended as calcium in milk can interfere with iron absorption. Offering the medication through a straw is the best option to ensure effective administration while minimizing side effects.
A toddler who is scheduled to have a lumbar puncture
A nurse is caring for a toddler who is scheduled to have a lumbar puncture. Which of the following actions should the nurse take?
- A. Restrain the toddler for 1 hr after the procedure.
- B. Swaddle the toddler in a warm blanket.
- C. Ask another nurse to assist with holding the toddler in a prone position.
- D. Place the toddler in a side-lying knee-chest position
Correct Answer: D
Rationale: The correct answer is D: Place the toddler in a side-lying knee-chest position. This position helps to open up the spaces between the vertebrae, making it easier for the healthcare provider to perform the lumbar puncture. Restraint is not recommended as it can cause distress and increase the risk of complications. Swaddling in a warm blanket may not provide the necessary positioning for the procedure. Asking another nurse to assist with holding the toddler in a prone position may not be as effective in achieving the optimal positioning needed for a lumbar puncture.
An infant
A nurse is collecting data from an infant. Which of the following sites is the most reliable location to check the infant's pulse?
- A. Apical
- B. Dorsalis pedis
- C. Temporal
- D. Carotid
Correct Answer: A
Rationale: The correct answer is A: Apical. The apical pulse, located at the apex of the heart, is the most reliable site to check an infant's pulse. It accurately reflects the heart rate and rhythm due to its proximity to the heart. The other choices are less reliable for infants: B (Dorsalis pedis) and C (Temporal) may be difficult to locate accurately on infants, D (Carotid) is not recommended for routine pulse checks in infants due to the risk of pressing too firmly on the delicate neck structures.
An infant with a large patent ductus arteriosus
A nurse is collecting data from an infant a large patent ductus arteriosus. Which of the following is clinical manifestations should the nurse expect?
- A. Machine like murmur
- B. Chronic hypoxemia
- C. Cyanosis with crying
- D. Weak pulse
Correct Answer: A
Rationale: The correct answer is A: Machine-like murmur. A patent ductus arteriosus (PDA) is a congenital heart defect where a blood vessel called the ductus arteriosus fails to close after birth, causing abnormal blood flow. The characteristic murmur associated with PDA is described as machine-like due to its continuous and loud nature. This murmur is heard best at the upper left sternal border. Other choices are incorrect because chronic hypoxemia (B) and cyanosis with crying (C) are more commonly seen in conditions like Tetralogy of Fallot or transposition of great vessels. Weak pulse (D) may be present in conditions like coarctation of the aorta.
A toddler receiving ear drops
While administering ear drops to a toddler, a nurse by pulls the auricle down and back. The mother asks, 'Why are you pulling the ear that way?' Which of the following responses should the nurse make?
- A. When I use this technique the medication will not run out of the ear.
- B. This opens the ear canal, allowing medication to reach the inner ear region.
- C. This is the safest and easiest way to administer this medication.
- D. When I use the technique, your child experiences less pain.
Correct Answer: B
Rationale: The correct answer is B: This opens the ear canal, allowing medication to reach the inner ear region. By pulling the auricle down and back, the nurse straightens the ear canal in toddlers, making it easier for the ear drops to reach the inner ear where they are most effective. This technique helps ensure that the medication is properly administered and absorbed.
Incorrect Answers:
A: When I use this technique the medication will not run out of the ear - This is incorrect because the aim of pulling the ear is not to prevent medication from running out but to facilitate its entry.
C: This is the safest and easiest way to administer this medication - This is incorrect as the safety and ease of administration are not the primary reasons for pulling the ear in this context.
D: When I use the technique, your child experiences less pain - This is incorrect as the main purpose of pulling the ear is not to reduce pain but to ensure effective delivery of the medication to the inner ear.