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A nurse is planning postoperative care for an adolescent following scoliosis repair with spinal instrumentation. Which of the following actions should the nurse include in the plan of care?
- A. Maintain the head of the bed at a 30° angle.
- B. Offer sips of water due to having surgery.
- C. Log roll the adolescent every 2 hours.
- D. Assist the adolescent to ambulate 12 hours following surgery.
Correct Answer: C
Rationale: The correct answer is C: Log roll the adolescent every 2 hours. This is important to prevent pressure ulcers and maintain spinal alignment post-surgery. Log-rolling involves turning the patient as a unit to avoid twisting the spine. Maintaining the head of the bed at a 30° angle (choice A) is important for respiratory function but not specific to spinal surgery. Offering sips of water (choice B) is generally appropriate after surgery but not specific to spinal instrumentation. Assisting the adolescent to ambulate (choice D) should be done gradually and with caution, typically starting with sitting on the bedside first, rather than a fixed time frame like 12 hours post-surgery.
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A nurse in a clinic is planning care for a child who has ADHD and is taking atomoxetine. Which of the following laboratory values should the nurse monitor?
- A. Liver function tests
- B. Kidney function tests
- C. Hemoglobin and hematocrit
- D. Serum sodium and potassium
Correct Answer: A
Rationale: The correct answer is A: Liver function tests. Atomoxetine, used to treat ADHD, can potentially cause liver injury. Monitoring liver function tests can help detect any liver abnormalities early on. Kidney function tests (B) are not typically affected by atomoxetine. Hemoglobin and hematocrit (C) are not directly impacted by this medication. Serum sodium and potassium (D) are not specifically associated with atomoxetine use.
A nurse is caring for a 9-year-old child at a clinic. The nurse should determine that the assessment findings are consistent with which of the following conditions?
- A. Edema
- B. Ecchymosis
- C. Pain Level
- D. Sensation
Correct Answer: B
Rationale: The correct answer is B: Ecchymosis. Ecchymosis is the presence of bruising, which is commonly seen in cases of trauma such as sprains, fractures, and dislocations. In a 9-year-old child, ecchymosis may indicate underlying injury or trauma. Edema can also be present in sprains, fractures, and dislocations, but it is not specific to these conditions. Pain level is subjective and can vary depending on the individual, so it is not as definitive as ecchymosis in identifying a specific condition. Sensation is important to assess in cases of injury, but it is not as indicative of a specific condition as ecchymosis. Therefore, the presence of ecchymosis is the most specific assessment finding to determine the underlying condition in this case. (0, 1, 0)
A nurse is caring for a school-age child who has sickle cell anemia and is in vaso-occlusive crisis. Which of the following actions should the nurse take?
- A. Apply cold compresses to the affected areas.
- B. Prepare for a transfusion of platelets.
- C. Promote active range of motion exercises.
- D. Increase oral fluid intake.
Correct Answer: D
Rationale: The correct answer is D: Increase oral fluid intake. During a vaso-occlusive crisis in sickle cell anemia, there is a blockage of blood flow leading to tissue ischemia and pain. Increasing oral fluid intake helps to hydrate the child and improve blood flow, potentially reducing the severity of the crisis. Cold compresses (A) can worsen vasoconstriction, platelet transfusion (B) is not indicated for vaso-occlusive crisis, and active range of motion exercises (C) can exacerbate pain and further compromise blood flow. Increasing fluid intake is the most appropriate intervention to help manage the crisis.
A nurse in the emergency department is caring for a 10-year-old child. The nurse is assessing the child. Which of the following findings require follow-up? Select the 5 findings that require follow-up.
- A. Temperature
- B. Heart rate
- C. Report of pain
- D. Respiratory rate
- E. Tonsillar findings
- F. Oxygen saturation
Correct Answer: A,B,C,D,E,F
Rationale: The correct answer includes all options (A, B, C, D, E, F) because they are essential vital signs and key indicators of the child's health status. Temperature (A), heart rate (B), respiratory rate (D), and oxygen saturation (F) are crucial physiological parameters that can indicate underlying health issues if abnormal. Report of pain (C) is important to assess the child's comfort and potential underlying conditions. Tonsillar findings (E) could indicate infections or other throat issues. Follow-up on all these findings is necessary for a comprehensive assessment of the child's health.
A nurse is caring for an infant who has necrotizing enterocolitis. Which of the following findings should the nurse expect?
- A. Hypertension
- B. Rounded abdomen
- C. Vomiting
- D. Tachypnea
Correct Answer: B,C,D
Rationale: The correct answer is B, C, and D. Necrotizing enterocolitis (NEC) in infants commonly presents with a rounded abdomen due to abdominal distension (B). Vomiting (C) is also a common symptom associated with NEC. Tachypnea (D) may occur due to abdominal distension and sepsis. Hypertension (A) is not typically associated with NEC in infants. The other choices are not provided, but based on typical NEC symptoms, they would not be expected in a patient with this condition.