Nokea
A nurse is planning care for a 12-year-old with rheumatic fever. The nurse should teach the parents to:
- A. Observe the child closely.
- B. Allow the child to participate in activities that will not tire him.
- C. Provide for adequate periods of rest between activities.
- D. Encourage someone in the family to be with the child 24 hours a day.
Correct Answer: C
Rationale: Rest is critical in rheumatic fever to reduce cardiac strain and prevent complications like carditis. Observation and limited activities are important, but rest is the priority.
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The nurse is discharging a baby with clubfoot who has had a cast applied. The nurse should provide additional teaching to the parents if they state:
- A. I should call if I see changes in the color of the toes under the cast.'
- B. I should use a pillow to elevate my child's foot as he sleeps.'
- C. My baby will need a series of casts to fix her foot.'
- D. Having a cast should not prevent me from holding my baby.'
Correct Answer: B
Rationale: Using a pillow to elevate the foot may alter the cast's corrective positioning, requiring additional teaching to avoid this practice.
The physician orders a urinalysis for a child who has undergone surgical repair of a hypospadias. Which of the following results should the nurse report to the physician?
- A. Urine specific gravity of 1.017.
- B. Ten red blood cells per high-powered field.
- C. Twenty-five white blood cells per high-powered field.
- D. Urine pH of 6.0.
Correct Answer: C
Rationale: High WBC count indicates infection.
The nurse identifies a nursing diagnosis of Risk for perioperative-positioning injury related to the surgical procedure for a school-age child scheduled for a tonsillectomy. Which of the following is an expected outcome for this nursing diagnosis?
- A. The child is able to tell about the surgery and recovery.
- B. The child remains on nothing-by-mouth (NPO) status for the designated preoperative period.
- C. The child and family demonstrate an understanding of the procedure.
- D. The child knows the parents will not leave.
Correct Answer: B
Rationale: The most appropriate outcome for a nursing diagnosis of Risk for perioperative-positioning injury related to the surgical procedure should be that the child remains NPO for the designated period of time before surgery, thereby minimizing the risk of aspiration during the surgery. Ability to tell about the surgery and demonstrating an understanding of the procedure are appropriate outcomes for a nursing diagnosis of Deficient knowledge. Knowing that the parents will not leave is associated with a nursing diagnosis of Anxiety or Fear related to separation from support systems or an unfamiliar environment.
The father of a neonate scheduled for gastrointestinal surgery asks the nurse how newborns respond to painful stimuli. Which of the following should be the nurse's best response?
- A. Newborns cry and cannot be distracted to stop crying.
- B. When faced with a pain, newborns try to roll away from it.
- C. Newborns typically move their whole body in response to pain.
- D. Pain causes the newborn to withdraw the affected part.
Correct Answer: C
Rationale: Newborns exhibit a generalized body response to pain, such as squirming or thrashing.
A transfusion of packed red blood cells has been ordered for a 1-year-old with sickle cell anemia. The infant has a 25 gauge I.V. infusing dextrose with sodium and potassium. Using the Situation, Background, Assessment, Recommendation (SBAR) method of communication, the nurse contacts the physician and recommends:
- A. Starting a second I.V. with a 22 gauge catheter to infuse normal saline with the blood.
- B. Using the existing I.V., but changing the fluids to normal saline for the transfusion.
- C. Replacing the I.V. with a 22 gauge catheter to infuse the ordered fluids.
- D. Starting a second I.V. with a 25 gauge catheter to infuse normal saline with the transfusion.
Correct Answer: A
Rationale: A second I.V. with a larger 22-gauge catheter ensures safe blood transfusion, as dextrose is incompatible and a 25-gauge is too small.