Nokea
A 14-month-old toddler who is 24 hr following interventions
A nurse is contributing to the plan of care of a 14-month-old toddler who is 24 h following interventions should the nurse include in the plan?
- A. Give the toddler a hard-tipped sippy cup to drink liquid
- B. Suction the toddler nose and mouth every hour
- C. Maintain elbow restraint
- D. Provide soft foods for the toddler
Correct Answer: D
Rationale: The correct answer is D: Provide soft foods for the toddler. At 14 months, toddlers should be transitioning to a diet of soft foods to aid in their development and prevent choking hazards. Hard-tipped sippy cups (choice A) are not recommended as they can pose a risk of injury. Suctioning the toddler's nose and mouth every hour (choice B) is excessive and can lead to irritation and discomfort. Maintaining elbow restraint (choice C) is unnecessary and may hinder the toddler's mobility and development. In summary, providing soft foods aligns with the toddler's age and promotes safe and appropriate feeding practices.
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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 9-year-old child who has acute rheumatic fever
A nurse is assisting with the admission of a 9-year-old child who has acute rheumatic fever. When obtaining the client's history, it is appropriate for the nurse to ask the parent which of the following questions?
- A. Has your son had a sore throat recently?
- B. Was your son born with this cardiac defect?
- C. Are you aware that your son will have to be in isolation?
- D. Has your child had any injuries recently?
Correct Answer: A
Rationale: Rationale: A sore throat can be a symptom of acute rheumatic fever, which is important for the nurse to assess. This can help in diagnosing the condition and planning appropriate care. Asking about a recent sore throat is relevant to the child's current health status and can guide further assessment and treatment.
Summary:
B: This question is not relevant to acute rheumatic fever.
C: Isolation is not necessary for acute rheumatic fever, so this question is not appropriate.
D: Recent injuries are not directly related to acute rheumatic fever and are not relevant to the child's current 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 child with asthma who weighs 4.69 kg
A child with asthma has the following medication ordered: Theophylline 4 mg/kg/dose every 6 hrs. The child weighs 4.69 kg. Calculate the appropriate dose.
- A. 33.6 mg
- B. 18.7 mg
- C. 8.4 mg
- D. 19 mg
Correct Answer: B
Rationale: To calculate the appropriate dose for the child, we first need to determine the child's weight in mg: 4.69 kg x 4 mg/kg = 18.76 mg. Since the dose is rounded to the nearest tenth, the correct dose is 18.7 mg (choice B). This calculation ensures the child receives the correct amount of medication based on their weight. Choices A, C, and D are incorrect as they do not accurately reflect the calculated dose.
A child who is postoperative following a tonsillectomy
A nurse is collecting data from a child who is postoperative following a tonsillectomy. Which of the following is a clinical manifestation of a hemorrhage?
- A. Drooling
- B. Continuous swallowing
- C. Poor fluid intake
- D. Increased pain
Correct Answer: B
Rationale: The correct answer is B: Continuous swallowing. This is a clinical manifestation of hemorrhage post-tonsillectomy as the child may be swallowing blood. Drooling (A) is more indicative of airway obstruction. Poor fluid intake (C) is a sign of dehydration. Increased pain (D) can be expected postoperatively but is not specific to hemorrhage.