Nokea
A nurse is caring for an adolescent following the application of a plaster cast for a fractured right tibia. Which of the following actions should the nurse take?
- A. Keep the client's leg in a dependent position.
- B. Use a hair dryer on a hot setting to dry the cast.
- C. Discourage the client from ambulating.
- D. Perform a neurovascular check of the lower extremities.
Correct Answer: D
Rationale: Neurovascular checks are essential to ensure that there is adequate blood flow and nerve function below the cast.
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A nurse is caring for an infant who is dehydrated and requires IV therapy. The nurse should monitor the infant's response to therapy by performing which of the following actions?
- A. Taking the infant's vital signs every 2 hr
- B. Counting the number of wet diapers every shift
- C. Weighing the infant at the same time every day
- D. Measuring the infant's head circumference twice per day
Correct Answer: C
Rationale: Daily weights are a critical measure of fluid balance in infants. A consistent daily weight check provides a direct and accurate assessment of the infant's hydration status and response to IV therapy.
A nurse is caring for a 2-week old Infant whose mother requests additional information about sudden infant death syndrome (SIDS). Which of the following responses should the nurse make?
- A. SIDS is directly correlated to diphtheria, tetanus, and pertussis vaccines.
- B. SIDS rates have been rising over the last 10 years.
- C. You should place your baby on her back when sleeping to decrease the risk of SIDS.
- D. Sleep apnea is the main cause of SIDS.
Correct Answer: C
Rationale: Placing a baby on their back to sleep significantly reduces the risk of SIDS.
A nurse is reinforcing teaching about methylphenidate (Ritalin) with the parents of a school-age child who has ADHD. Which of the following instructions should the nurse include?
- A. You should give your child's last daily dose of the medication before 6 o'clock in the evening.
- B. You will need to give your child the medication after meals.
- C. You will need to have your child's blood glucose level checked monthly.
- D. You should not give your child the medication on weekends.
Correct Answer: A
Rationale: Methylphenidate is a stimulant and giving it too late in the day can cause insomnia.
A nurse is caring for an Infant who has spina bifida. Which of the following actions should the nurse take?
- A. Perform range-of-motion (ROM) exercises to the infant's hips.
- B. Place the infant in a prone position.
- C. Feed the infant through an NG tube.
- D. Cover the infant's lesion with a dry cloth.
Correct Answer: B
Rationale: This helps prevent pressure on the spina bifida lesion and minimizes the risk of injury or infection.
A nurse is caring for a child who has juvenile rheumatoid arthritis. Which of the following actions should the nurse take?
- A. Maintain night splints to the affected joint.
- B. Encourage the child to take daytime naps.
- C. Administer opioids on a schedule.
- D. Apply cool compresses for 20 min every hour.
Correct Answer: A
Rationale: Night splints help maintain joint position and function during sleep, preventing contractures and deformities. This is a common intervention in managing juvenile rheumatoid arthritis to ensure proper joint alignment and minimize pain and stiffness.