Nokea
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.
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A nurse is caring for a toddler who had a cast applied 2 hr ago due to multiple fractures of the right hand. Which of the following findings should the nurse report immediately to the charge nurse?
- A. The parent reports the child will not keep the arm elevated on the pillow.
- B. The fingers on the right hand have a capillary refill of 4 seconds.
- C. The fingertips of the right hand are swollen and bruised.
- D. The child is not attempting to move her right arm or fingers.
Correct Answer: B
Rationale: A capillary refill time of more than 2 seconds indicates poor perfusion which can be a sign of compartment syndrome.
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 assisting with the admission of a 2-year-old toddler who has acute gastroenteritis. Which of the following actions should the nurse take first?
- A. Determine if the toddler is voiding.
- B. Request evaluation of the toddler's serum electrolytes.
- C. Initiate isotonic fluids with 20 mEq/L potassium chloride.
- D. Collect a stool sample from the toddler.
Correct Answer: A
Rationale: Assessing urine output is crucial for determining the child's hydration status. Voiding is an important indicator of kidney function and fluid balance.
A nurse is reinforcing teaching with the parents of a preschooler who has atopic dermatitis. Which of the following information should the nurse include?
- A. You will need to take the entire prescription of antibiotics even if your symptoms improve.
- B. The doctor will remove the lesions with liquid nitrogen.
- C. The doctor might recommend an antihistamine to help control your symptoms.
- D. You can relieve your child's discomfort by applying warm compresses to the lesions.
Correct Answer: C
Rationale: Antihistamines can help reduce itching and provide relief which is a common symptom of atopic dermatitis.
A nurse is reinforcing teaching about pediculus capitis with the parents of a school-age child at a well-child visit. Which of the following Information should the nurse include?
- A. Lice can jump from one child to another.
- B. Washing your child's hair daily will prevent lice.
- C. Lice do not survive away from the host.
- D. Encourage your child to avoid sharing hats with other children.
Correct Answer: D
Rationale: Sharing hats or other personal items can facilitate the transmission of lice from one child to another.