Nokea
An infant
A nurse is collecting data from an infant. Which of the following sites is the most reliable location to check the infant's pulse?
- A. Apical
- B. Dorsalis pedis
- C. Temporal
- D. Carotid
Correct Answer: A
Rationale: The correct answer is A: Apical. The apical pulse, located at the apex of the heart, is the most reliable site to check an infant's pulse. It accurately reflects the heart rate and rhythm due to its proximity to the heart. The other choices are less reliable for infants: B (Dorsalis pedis) and C (Temporal) may be difficult to locate accurately on infants, D (Carotid) is not recommended for routine pulse checks in infants due to the risk of pressing too firmly on the delicate neck structures.
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A child who is experiencing an acute asthma attack
A nurse is caring for a child who is experiencing an acute asthma attack. Which of the following medications should the nurse administer first?
- A. Methylprednisolone
- B. Albuterol
- C. Fluticasone
- D. Beclomethasone
Correct Answer: B
Rationale: The correct answer is B: Albuterol. During an acute asthma attack, bronchodilation is crucial to relieve airway constriction quickly. Albuterol is a short-acting beta-agonist that acts rapidly to relax the airway muscles, allowing for improved airflow. Methylprednisolone (A) is a corticosteroid that is used for long-term control, not for immediate relief. Fluticasone (C) and Beclomethasone (D) are inhaled corticosteroids for maintenance therapy and do not provide immediate relief during an acute attack. Administering Albuterol first is essential to address the acute symptoms and stabilize the child's condition.
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.
A 2-month-old infant who has just undergone cleft palate repair
A nurse is contributing to the plan of care for a 2-month-old infant who has just undergone cleft palate repair. The nurse should contribute which of the following interventions to the client's plan of care?
- A. Keep the infant in a side-lying position.
- B. Remove elbow restraints while the infant is sleeping
- C. Administer pain medication around the clock for the first 72 hr.
- D. Feed the infant half-strength formula for the first 48 hr
Correct Answer: C,D
Rationale: Correct Answer: C, D
Rationale:
C: Administer pain medication around the clock for the first 72 hr to ensure adequate pain management post-cleft palate repair.
D: Feed the infant half-strength formula for the first 48 hr to prevent potential aspiration and promote healing.
Summary:
A: Keeping the infant in a side-lying position is not directly related to cleft palate repair care.
B: Removing elbow restraints while the infant is sleeping may increase the risk of self-injury.
E, F, G: No additional information provided, so cannot determine their relevance.
An infant who has Tetralogy of Fallot and is easily fatigued when eating
A nurse is caring for an infant who has Tetralogy of Fallot and notes that the infant is easily fatigued when eating. Which defect is not present in this cardiac congenital malformation?
- A. Overriding aorta
- B. Pulmonary stenosis
- C. Left ventricular hypertrophy
- D. Ventricular septal defect
Correct Answer: C
Rationale: The correct answer is C: Left ventricular hypertrophy is not present in Tetralogy of Fallot. In Tetralogy of Fallot, the four main defects are pulmonary stenosis, overriding aorta, ventricular septal defect, and right ventricular hypertrophy. Left ventricular hypertrophy is not part of the condition. The infant's fatigue during feeding is likely due to decreased oxygen levels in the blood caused by the pulmonary stenosis and right-to-left shunting at the ventricular septal defect. Choices A, B, and D are all components of Tetralogy of Fallot, making them incorrect options.
A 3-month-old infant receiving oral elixir
A nurse is preparing to administer an oral elixir to a 3-month-old infant using an oral medication syringe. Which of the following actions should the nurse plan to take?
- A. Measure the elixir in a medicine cup before transferring to a syringe
- B. Place the infant supine in a crib prior to administration.
- C. Position the syringe to the side of the infant's tongue.
- D. Mix the medication with 10 mL of formula.
Correct Answer: C
Rationale: The correct answer is C: Position the syringe to the side of the infant's tongue. This is the correct action as it helps prevent choking and aspiration in infants. Placing the syringe to the side allows the infant to swallow the medication more effectively while reducing the risk of it going down the wrong pipe. It also encourages a natural swallowing reflex.
Choice A is incorrect because measuring in a medicine cup before transferring to a syringe may lead to inaccuracies in dosage. Choice B is incorrect as placing the infant supine increases the risk of choking. Choice D is incorrect as mixing medication with formula may interfere with the medication's effectiveness.