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A nurse is caring for an adolescent who is having a sickle cell crisis. Which of the following nursing actions should the nurse take?
- A. Assist with administering a blood transfusion.
- B. Withhold opioids to avoid dependence.
- C. Encourage exercise.
- D. Initiate a 2 L/day fluid restriction.
Correct Answer: A
Rationale: Blood transfusions are often necessary in sickle cell crisis to manage severe anemia and improve oxygen delivery.
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A nurse is caring for a 7-year-old client who has an upper respiratory infection and a history of type 1 diabetes mellitus. Which of the following statements by the mother indicates a need for further instruction?
- A. I will notify the doctor if his temperature is not controlled with acetaminophen.
- B. I will continue to check his blood sugar two times every day.
- C. I will report a change in breathing or signs of confusion.
- D. I will encourage him to drink a half a cup of water or sugar-free fluid every 30 minutes.
Correct Answer: B
Rationale: Checking blood sugar only twice a day is insufficient during illness especially for a child with type 1 diabetes. Blood glucose levels can fluctuate significantly due to infection and more frequent monitoring (at least 4 times a day or as recommended) is necessary.
A nurse is caring for a 4-year-old child who has dehydration. Which of the following findings should the nurse identify as the priority?
- A. Sodium 142 mEq/L
- B. Urine specific gravity 1.025
- C. Potassium 2.5 mEq/L
- D. Blood glucose 110 mg/Dl
Correct Answer: C
Rationale: Potassium 2.5 mEq/L is below the normal range for potassium (3.5-5.0 mEq/L) and indicates hypokalemia which can cause serious cardiac issues and muscle weakness.
A nurse is collecting data from a 4-year-old child. Which of the following findings should the nurse expect?"
- A. Heart rate 110/min
- B. Capillary refill greater than 3 seconds
- C. Weight gain of 0.9 kg (2 lb) in a year
- D. Respiratory rate 32/min
Correct Answer: A
Rationale: A heart rate of 110 beats per minute is within the normal range for a 4-year-old child. The typical heart rate for this age is between 80 to 120 beats per minute.
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. Place the toddler in a side-lying
- C. knee-chest position.
- D. Ask another nurse to assist with holding the toddler in a prone position.
- E. Swaddle the toddler in a warm blanket.
Correct Answer: B
Rationale: This position helps to open the spaces between vertebrae, facilitating the lumbar puncture.
A nurse is collecting data from an infant who has a large patent ductus arteriosus. Which of the following is clinical manifestations should the nurse expect?
- A. Cyanosis with crying
- B. Weak pulses
- C. Chronic hypoxemia
- D. Machine-like murmur
Correct Answer: D
Rationale: A characteristic feature of PDA is a continuous