Nokea
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.
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A child who has suspected cystic fibrosis
A nurse is reinforcing teaching about diagnostic tests with the parents of a child who has suspected cystic fibrosis. Which of the following diagnostic tests should the nurse include as the most definitive when diagnosing cystic fibrosis?
- A. Pulmonary function test
- B. Sweat chloride test
- C. Stool fat content analysis
- D. Sputum culture
Correct Answer: B
Rationale: The correct answer is B: Sweat chloride test. This test is the most definitive diagnostic tool for cystic fibrosis as it measures the concentration of chloride in sweat, which is typically elevated in individuals with the condition. The other choices are not as specific to cystic fibrosis. A pulmonary function test (A) evaluates lung function but does not specifically diagnose cystic fibrosis. Stool fat content analysis (C) is used to assess fat malabsorption but does not confirm cystic fibrosis. Sputum culture (D) is used to identify respiratory infections but is not specific to cystic fibrosis.
A school-age child who has cystic fibrosis
A nurse is reinforcing teaching with the parents of a school-age child who has cystic fibrosis. Which of the following statements should the nurse make?
- A. Your child's diet should be high in carbohydrates & proteins with no restriction of fats.
- B. Limit your child's intake of sodium to avoid complications.
- C. A pigeon-shaped chest might become evident as the disease progresses.
- D. Administer a bronchodilator to the child after chest percussion therapy.
Correct Answer: C
Rationale: The correct answer is C: A pigeon-shaped chest might become evident as the disease progresses. In cystic fibrosis, the chest may appear pigeon-shaped due to the abnormal growth of the ribs and sternum. This is caused by chronic respiratory issues and increased work of breathing. It is important for the nurse to educate the parents about this potential physical manifestation of the disease so they can monitor their child's condition closely.
Incorrect choices:
A: Your child's diet should be high in carbohydrates & proteins with no restriction of fats - This is incorrect as children with cystic fibrosis often require a high-calorie, high-fat diet to meet their increased energy needs.
B: Limit your child's intake of sodium to avoid complications - While monitoring sodium intake can be important for some conditions, it is not a primary concern in cystic fibrosis.
D: Administer a bronchodilator to the child after chest percussion therapy - While bronchodilators may be used in cystic fib
A child who has Kawasaki disease
A nurse is caring for a child who has Kawasaki disease. Which of the following systems is primarily affected by this disease?
- A. Respiratory
- B. Gastrointestinal
- C. Cardiovascular
- D. Integumentary
Correct Answer: C
Rationale: The correct answer is C: Cardiovascular. Kawasaki disease primarily affects the cardiovascular system, causing inflammation of blood vessels, particularly the coronary arteries. This can lead to complications such as coronary artery aneurysms and myocarditis. The other choices are incorrect because Kawasaki disease does not primarily affect the respiratory, gastrointestinal, or integumentary systems. The key feature of Kawasaki disease is the inflammation of blood vessels, which is why the cardiovascular system is the primary system affected.
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.
A child who is to receive percussion, vibration, and postural drainage
A nurse is caring for a child who is to receive percussion, vibration, and postural drainage. Which of the following actions should the nurse take first?
- A. Instruct the client to cough
- B. Perform vibration while the client exhales slowly through the nose.
- C. Percuss the upper posterior chest.
- D. Administer albuterol by nebulizer.
Correct Answer: D
Rationale: The correct answer is D: Administer albuterol by nebulizer. This should be done first to help open up the airways and facilitate the effectiveness of the subsequent treatments. Albuterol is a bronchodilator that helps to relax the muscles in the airways, making it easier for the child to breathe. Administering albuterol before percussion, vibration, and postural drainage will help optimize the child's lung function and overall response to the respiratory therapy.
Choice A: Instruct the client to cough - This can be done after administering albuterol to help clear any loosened secretions.
Choice B: Perform vibration while the client exhales slowly through the nose - This can be done after administering albuterol to further aid in loosening and mobilizing secretions.
Choice C: Percuss the upper posterior chest - This can be done after administering albuterol to assist in clearing secretions from the lungs.