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An adolescent who is having a sickle cell crisis
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. withhold opioids to avoid dependence
- B. Assist RN with administering a blood transfusion
- C. Initiate a 2 L/day fluid restriction
- D. Encourage exercise
Correct Answer: B
Rationale: The correct answer is B: Assist RN with administering a blood transfusion. During a sickle cell crisis, blood transfusions can help improve oxygen delivery to tissues by increasing the number of normal red blood cells. This can help alleviate symptoms and prevent complications. Withholding opioids (choice A) can lead to inadequate pain management. Initiation of fluid restriction (choice C) is inappropriate as hydration is crucial during a sickle cell crisis. Encouraging exercise (choice D) can worsen the crisis by increasing the risk of vaso-occlusive events.
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A school-age child who has cystic fibrosis
A nurse is reinforcing teaching with the parents of a school-age child who has cystic fibrosis. Which of the following statements should the nurse make?
- A. Your child's diet should be high in carbohydrates & proteins with no restriction of fats.
- B. Limit your child's intake of sodium to avoid complications.
- C. A pigeon-shaped chest might become evident as the disease progresses.
- D. Administer a bronchodilator to the child after chest percussion therapy.
Correct Answer: C
Rationale: The correct answer is C: A pigeon-shaped chest might become evident as the disease progresses. In cystic fibrosis, the chest may appear pigeon-shaped due to the abnormal growth of the ribs and sternum. This is caused by chronic respiratory issues and increased work of breathing. It is important for the nurse to educate the parents about this potential physical manifestation of the disease so they can monitor their child's condition closely.
Incorrect choices:
A: Your child's diet should be high in carbohydrates & proteins with no restriction of fats - This is incorrect as children with cystic fibrosis often require a high-calorie, high-fat diet to meet their increased energy needs.
B: Limit your child's intake of sodium to avoid complications - While monitoring sodium intake can be important for some conditions, it is not a primary concern in cystic fibrosis.
D: Administer a bronchodilator to the child after chest percussion therapy - While bronchodilators may be used in cystic fib
A school-age child who has respiratory failure due to pneumonia
A nurse is assisting with the care of a school-age child who has respiratory failure due to pneumonia. Which of the following positions should the nurse encourage to allow maximal lung expansion?
- A. Upright
- B. Supine
- C. Prone
- D. Side-lying
Correct Answer: A
Rationale: The correct answer is A: Upright. In an upright position, gravity helps to maximize lung expansion by allowing the diaphragm to descend fully. This position promotes better ventilation and oxygenation by reducing the pressure on the lungs. Supine (B), prone (C), and side-lying (D) positions can limit lung expansion and compromise breathing mechanics. These positions may cause the abdominal contents to compress the lungs, reducing their ability to expand fully. Therefore, encouraging the child to sit upright will optimize lung function and promote effective gas exchange.
A child with pneumonia who weighs 20 lb
Primary care provider orders cefazolin (Kefrol) 30 mg/kg in two divided doses per day for a child with pneumonia. Child weighs 20 lb. If the available oral suspension is 125 mg/5ml how many mls per dose should the child receive?
- A. 5.4 mL
Correct Answer: A
Rationale: To calculate the dose, we first convert the child's weight to kg: 20 lb / 2.2 = 9.09 kg. Next, we calculate the total daily dose: 30 mg/kg * 9.09 kg = 272.7 mg/day. Since the dose is divided into 2, each dose is 272.7 mg / 2 = 136.35 mg. To find the volume needed, we divide the dose by the concentration of the suspension: 136.35 mg / 125 mg/5ml = 1.09 ml. However, the dose is divided into two, so each dose is 1.09 ml * 2 = 2.18 ml. Rounded to 1 decimal, the child should receive 2.2 ml per dose, closest to option A: 5.4 ml. Other choices are incorrect as they do not align with the calculated dose.
An 8-month-old infant who will be admitted for surgery
A nurse is reinforcing teaching with the parents of an 8-month-old infant who will be admitted for surgery. Which of the following instructions should the nurse include in the teaching?
- A. You should begin to manipulate the infant's bedtime based on the hospitals visiting hours.
- B. You should bring the infant's favorite blanket to the hospital
- C. You should read the child a story about hospitalization.
- D. You will need to go home when it is not visiting hours.
Correct Answer: B,C
Rationale: The correct answer is B and C. Bringing the infant's favorite blanket to the hospital (B) provides comfort and familiarity in an unfamiliar environment, reducing anxiety. Reading the child a story about hospitalization (C) can help prepare the child for the upcoming experience, easing fears.
Choice A is incorrect because manipulating bedtime based on visiting hours disrupts the infant's routine. Choice D is incorrect as parents are usually allowed to stay with their child in the hospital. Choices E, F, and G are not provided in the question.
In summary, choices B and C are crucial for providing comfort and emotional support to the infant before surgery, while the other options either disrupt the routine or are not necessary for the child's well-being during hospitalization.
A child who has hemophilia
A nurse is reinforcing teaching about controlling a bleeding episode with a parent of a child who has hemophilia. Which of the following statements by the parent indicates a need for further teaching?
- A. I will elevate the affected area if possible.
- B. I will apply warm compresses over the site.
- C. I will have my child rest.
- D. I will promptly immobilize the involved area to relieve pain & decrease bleeding.
Correct Answer: B
Rationale: The correct answer is B because applying warm compresses can worsen bleeding in hemophilia by dilating blood vessels. Elevating the affected area helps reduce blood flow to the site, aiding in clot formation. Resting minimizes movement that could exacerbate bleeding. Promptly immobilizing the area helps reduce pain and prevent further bleeding. Therefore, the incorrect choice (B) contradicts the principles of managing bleeding in hemophilia.