Nokea
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.
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A nurse is teaching the parents of a child who has diabetes mellitus about the manifestations of hypoglycemia. Which of the following manifestations should the nurse include in the teaching?
- A. Fruity breath odor
- B. Diaphoresis
- C. Dry mucous membranes
- D. Polyuria
Correct Answer: B
Rationale: Diaphoresis is a common symptom of hypoglycemia due to the activation of the sympathetic nervous system.
A nurse is preparing to administer a dexamethasone 1.5 mg/kg/day PO to divide equally every 6 hr to a preschool-age child who weighs 22 lb. Available is dexamethasone oral solution 1 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
- A. 3.8 mL
- B. 2.8 mL
- C. 4.8 mL
- D. 1.8 mL
Correct Answer: 3.8
Rationale: Calculation: 22 lb ÷ 2.2 = 10 kg; 1.5 mg/kg/day × 10 kg = 15 mg/day; 15 mg ÷ 4 doses = 3.75 mg/dose; 3.75 mg × 1 mL/1 mg = 3.8 mL.
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 talking with a 13-year-old female client who is having her annual health-screening visit. Which of the following comments by the client should concern the nurse?
- A. My parents treat me like a baby sometimes.
- B. There's a pimple on my face, and I worry that everyone will notice it.
- C. I start taking ibuprofen a few days before my period starts.
- D. None of the kids at my school like me, and I don't like them either.
Correct Answer: D
Rationale: This statement indicates social isolation and potential issues with peer relationships which can be a red flag for emotional distress or depression.
A nurse in a clinic is preparing to administer pre-kindergarten vaccines to a 5-year-old child whose medical record indicates that his Immunizations are up to date. Which of the following vaccines should the nurse plan to administer?
- A. Hepatitis B (HBV)
- B. Measles
- C. mumps
- D. and rubella (MMR)
- E. Haemophilus influenzae type B (Hib)
- F. Pneumococcal conjugate vaccine (PCV)
Correct Answer: B
Rationale: The MMR vaccine is part of the pre-kindergarten immunization schedule.