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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.
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A nurse is reinforcing car seat safety instructions with the parents of a 15-month-old toddler. Which of the following statements by the parents indicates an understanding of the teaching?
- A. I should place my child in a forward-facing car seat to ensure safety.
- B. I should place my child in the front seat in a rear-facing car seat.
- C. I should continue to use a booster seat until my child is 5 years old.
- D. I should place my child in a rear-facing car seat until age 2.
Correct Answer: D
Rationale: Rear-facing car seats until age 2 protect the child's head, neck, and spine. Forward-facing too early, front-seat placement, or premature booster use increase injury risk.
A nurse is assisting with the care of an infant who is postoperative following surgical repair of a cleft lip and palate. Which of the following action should the nurse plan to take?
- A. Gently rub betadine on the infant's incisions to prevent infection.
- B. Place the infant in a prone position for 1 hr to facilitate drainage of secretions.
- C. Weigh the infant once each day using the same scale.
- D. Suction the infant's nose and mouth using an in-line device on the lowest setting.
Correct Answer: C
Rationale: Daily weighing monitors fluid status post-surgery. Betadine risks irritation, prone positioning may obstruct airways, and suctioning could harm the surgical site.
A nurse is preparing to perform a heel stick on an infant. Which of the following actions should the nurse take?
- A. Use an automated lancet device to puncture the heel.
- B. Apply limb restraints to the infant.
- C. Puncture the heel at the inner aspect of the heel.
- D. Cleanse the area with povidone iodine.
Correct Answer: A
Rationale: An automated lancet device ensures a controlled puncture, minimizing discomfort. Restraints are unnecessary, the inner heel is not the correct site, and povidone iodine is not typically used for heel sticks.
A nurse is planning to reinforce teaching about head injuries with a group of parents of school-age children. The nurse should instruct the parents to monitor for and report which of the following manifestations?
- A. Insomnia
- B. Irritability
- C. Diarrhea
- D. Hypothermia
Correct Answer: B
Rationale: Irritability may signal increased intracranial pressure post-head injury, requiring prompt reporting. Insomnia, diarrhea, and hypothermia are less directly related.
A nurse in a provider's office is collecting data from an adolescent who has juvenile idiopathic arthritis and has been taking ibuprofen daily for the last 6 months. Which of the following client statements should the nurse report to the provider?
- A. I have morning stiffness in my joints.
- B. I have been taking a multivitamin that contains iron.
- C. I noticed some blood in my stool this morning.
- D. I skipped taking my ibuprofen last week after I went swimming.
Correct Answer: C
Rationale: Blood in stool suggests possible GI bleeding from long-term ibuprofen use, requiring urgent reporting. Stiffness is expected, vitamins are benign, and a single missed dose is less critical.