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A nurse is collecting data from a toddler who has heart failure. Which of the following findings should the nurse expect?
- A. Weight loss of 0.9 kg (2 lb)
- B. Heart rate 65/min
- C. Bounding peripheral pulses
- D. Decreased urine output
Correct Answer: D
Rationale: Decreased urine output is expected in heart failure due to poor renal perfusion. Weight gain, not loss, is typical, and heart rate is usually elevated, not normal. Pulses are often weak.
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A nurse is caring for a child who has pertussis. Which of the following precautions should the nurse initiate?
- A. Droplet
- B. Contact
- C. Airborne
- D. Protective
Correct Answer: A
Rationale: Pertussis spreads via respiratory droplets, requiring droplet precautions. Contact precautions are for direct contact diseases, airborne for smaller particles like TB, and protective precautions are for immunocompromised patients.
A nurse is contributing to the plan of care for a child who has nephrotic syndrome and a prescription for corticosteroids. Which of the following interventions should the nurse recommend?
- A. Provide a low-sodium diet.
- B. Encourage increased fluid intake.
- C. Obtain urine ketone levels weekly.
- D. Administer pancreatic enzymes with each meal.
Correct Answer: A
Rationale: A low-sodium diet manages fluid retention in nephrotic syndrome. Increased fluids worsen edema, urine ketones are irrelevant, and pancreatic enzymes are not indicated.
A nurse is obtaining a sputum sample from a school-age child. Which of the following actions should the nurse take?
- A. Ask the child to cough deeply.
- B. Ask the child to clear their throat.
- C. Use wall suction to obtain the sample from the child's throat.
- D. Use a bulb syringe to obtain sputum from the child's mouth.
Correct Answer: A
Rationale: Asking the child to cough deeply helps obtain a sputum sample from the lower respiratory tract. Clearing the throat, wall suction, or bulb syringe are less effective or inappropriate methods.
A nurse is reviewing the medical record of a school-age child who is current on recommended immunizations. Which of the following immunizations should the nurse plan to administer at the 11-year-old well-child visit?
- A. Tetanus, diphtheria, acellular pertussis (Tdap)
- B. Haemophilus influenzae type b (Hib)
- C. Inactivated poliovirus (IPV)
- D. Rotavirus (RV)
Correct Answer: A
Rationale: Tdap is recommended at 11-12 years as a booster. Hib, IPV, and RV are given in infancy, not at this age.
A nurse is collecting data from a child who recently experienced a psychomotor seizure. Which of the following findings should the nurse expect?
- A. Hyperactivity
- B. Nystagmus
- C. Apnea
- D. Amnesia
Correct Answer: D
Rationale: Amnesia is common post-psychomotor seizure. Hyperactivity, nystagmus, or apnea are not typical postictal findings.