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A nurse is caring for an infant who has diaper dermatitis. Which of the following actions should the nurse take?
- A. Apply talcum powder to the irritated area.
- B. Wipe stool from the skin using store-bought baby wipes.
- C. Apply zinc oxide ointment to the irritated area.
- D. Wipe urine from the skin using a cool cloth.
Correct Answer: C
Rationale: The correct answer is C: Apply zinc oxide ointment to the irritated area. Zinc oxide ointment provides a protective barrier on the skin, helping to soothe and heal diaper dermatitis. It also helps to keep moisture away from the irritated skin, promoting healing.
Incorrect options:
A: Applying talcum powder can further irritate the skin as it can be abrasive.
B: Store-bought baby wipes may contain chemicals or fragrances that can worsen the condition.
D: Wiping urine with a cool cloth is a good practice, but it does not address the issue of diaper dermatitis.
Overall, option C is the best choice as it directly addresses the diaper dermatitis by providing a protective barrier and promoting healing.
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A nurse is caring for a 1-month-old infant who has manifestations of severe dehydration and a prescription for parenteral fluid therapy. The guardian asks, 'What are the indications that my baby needs an IV?' Which of the following responses should the nurse make?
- A. Your baby needs an IV because she is not producing tears.
- B. Your baby needs an IV because her heart rate is decreased.
- C. Your baby needs an IV because she is breathing slower than normal.
- D. Your baby needs an IV because her fontanels are bulging.
Correct Answer: A
Rationale: The correct response is A: Your baby needs an IV because she is not producing tears. In infants, the inability to produce tears is a sign of severe dehydration, indicating a deficit in body fluids. Tears are composed of water and electrolytes, and the absence of tears suggests a significant fluid imbalance. This makes it crucial to administer parenteral fluid therapy via an IV to restore hydration levels.
Choices B, C, and D are incorrect because they do not directly correlate with the need for IV fluid therapy in this scenario. A decreased heart rate, slower breathing, and bulging fontanels may be signs of distress or other issues but do not specifically indicate the need for immediate IV fluid administration due to dehydration. Therefore, option A is the most appropriate and relevant response given the infant's presentation of severe dehydration.
A nurse is assessing a 7-year-old child who has diabetes. Which of the following findings should the nurse identify as a manifestation of hypoglycemia?
- A. Increased capillary refill
- B. Thirst
- C. Shakiness
- D. Decreased appetite
Correct Answer: C
Rationale: The correct answer is C: Shakiness. Hypoglycemia in a child with diabetes can lead to a decrease in blood sugar levels, causing symptoms like shakiness due to the body's response to low glucose levels. Increased capillary refill (A) is not typically associated with hypoglycemia. Thirst (B) is more commonly seen in hyperglycemia. Decreased appetite (D) can be a symptom of hypoglycemia, but shakiness is a more specific indicator.
A nurse is preparing to admit a 6-year-old with varicella to the pediatric unit. Which of the following actions should the nurse take?
- A. Assign the child to a negative air pressure room.
- B. Administer aspirin to the child for fever.
- C. Use droplet precautions when caring for the child.
- D. Assess the child for Koplik spots.
Correct Answer: A
Rationale: The correct answer is A: Assign the child to a negative air pressure room. Varicella, commonly known as chickenpox, is highly contagious and spreads through respiratory droplets. Placing the child in a negative air pressure room helps prevent the spread of the virus to others by containing the infectious particles within the room. This isolation measure is crucial in protecting both the child and other patients.
Choice B is incorrect because aspirin should not be administered to children with varicella due to the risk of Reye's syndrome. Choice C is incorrect as droplet precautions are not necessary for varicella, which primarily spreads through airborne respiratory droplets. Choice D is incorrect as Koplik spots are associated with measles, not varicella.
A nurse is assessing a school-age child who is receiving prednisone. For which of the following adverse effects should the nurse monitor?
- A. Renal failure
- B. Stevens-Johnson syndrome
- C. Prolonged wound healing
- D. Hypotension
Correct Answer: C
Rationale: The correct answer is C: Prolonged wound healing. Prednisone is a corticosteroid that can suppress the immune system and delay wound healing due to its anti-inflammatory effects. The nurse should monitor for this adverse effect by assessing the child's wounds regularly for signs of slow or impaired healing. Renal failure (A) is not a common adverse effect of prednisone. Stevens-Johnson syndrome (B) is a severe skin reaction usually caused by medications but is not typically associated with prednisone. Hypotension (D) is not a common adverse effect of prednisone and is more commonly associated with other medications or conditions.
A nurse on the pediatric unit is admitting the child from the emergency department. Complete the following sentence by using the lists of options. The nurse suspects the child is experiencing rheumatic fever. The nurse should recognize the child is at greatest risk of developing--- due to---
- A. Glomerulonephritis
- B. Pericarditis
- C. Rheumatic heart disease
- D. Streptococcal pharyngitis
- E. Recent immunizations
- F. Viral infection
Correct Answer: C,D
Rationale: The correct answers are C: Rheumatic heart disease and D: Streptococcal pharyngitis. Rheumatic fever is caused by untreated streptococcal infection. If not treated promptly, it can lead to rheumatic heart disease, a serious complication. Streptococcal pharyngitis is a common precursor to rheumatic fever. Glomerulonephritis (A) is a potential complication of streptococcal infection but not directly related to rheumatic fever. Pericarditis (B) is an inflammation of the pericardium and not directly associated with rheumatic fever. Recent immunizations (E) and viral infections (F) are not linked to the development of rheumatic fever.