Nokea
A nurse is collecting data from an infant who hit her head when she fell off of a dressing table. The nurse should identify which of the following findings as indicating increased intracranial pressure?
- A. Brisk pupillary reaction to light
- B. Irritability
- C. Tachycardia
- D. Increased sensory response to painful stimuli
Correct Answer: B
Rationale: Irritability is a common early sign of increased ICP in infants. Changes in behaviour such as increased irritability or lethargy can indicate a neurological problemincluding increased pressure within the skull.
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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. Montelukast
- C. Albuterol
- D. Fluticasone
Correct Answer: C
Rationale: Albuterol is a short-acting beta-agonist that provides rapid bronchodilation. It is the first-line medication for immediate relief of bronchospasm during an acute asthma attack.
A nurse is caring for a school-age child who has a new plaster cast on her right arm. Which of the following actions should the nurse take?
- A. Place a warm
- B. moist heat pack on the cast.
- C. Position the casted arm in a dependent position.
- D. Move the casted arm with a firm grasp.
- E. Administer diphenhydramine to relieve itching.
Correct Answer: D
Rationale: Itching is common under a new cast and diphenhydramine can help manage this symptom without risking damage to the cast
A nurse is preparing to administer acetaminophen 15 mg/kg PO to a preschool child for fever. The child weighs 30 lb. Available is acetaminophen liquid 160 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
- A. 6.4 mL
- B. 5.4 mL
- C. 7.4 mL
- D. 4.4 mL
Correct Answer: 6.4
Rationale: Calculation: 30 lb × 0.454 kg/lb = 13.62 kg; 15 mg/kg × 13.62 kg = 204.3 mg; 204.3 mg ÷ 160 mg/5 mL = 6.4 mL.
A nurse is caring for a preschooler who has epiglottitis from a streptococcal infection. Which of the following actions should the nurse take?
- A. Attempt to obtain a throat culture.
- B. Use a tongue depressor to observe the back of the throat.
- C. Apply humidified oxygen via a mask.
- D. Initiate airborne precautions.
Correct Answer: C
Rationale: This helps to keep the airways moist and can provide some relief and improve oxygenation.
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.