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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 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.
A nurse is preparing to administer immunizations to a 5-year-old child who is up to date with the current immunization schedule. Which of the following immunizations should the nurse plan to administer?
- A. Haemophilus influenzae type B
- B. Varicella
- C. Hepatitis B
- D. Diphtheria
Correct Answer: B
Rationale: The correct answer is B: Varicella. At the age of 5, children are due for their second dose of the Varicella vaccine according to the current immunization schedule. Varicella vaccine is given to protect against chickenpox. Haemophilus influenzae type B and Hepatitis B vaccines are typically administered at earlier ages. Diphtheria vaccine is usually given in combination with other vaccines and not as a standalone. In summary, Varicella is the correct choice as it aligns with the child's age and the recommended immunization schedule, while the other options are not due at this time.
A nurse is caring for a toddler who has acute lymphocytic leukemia. In which of the following activities should the nurse expect the child to participate?
- A. Using scissors to cut out paper shapes
- B. Playing with a large plastic truck
- C. Looking at alphabet flash cards
- D. Watching a cartoon in the activity room
Correct Answer: D
Rationale: The correct answer is D: Watching a cartoon in the activity room. Toddlers with acute lymphocytic leukemia are often immunocompromised, making them susceptible to infections. Therefore, activities that involve potential injury or exposure to germs, such as using scissors (choice A) or playing with toys that cannot be easily cleaned (choice B) should be avoided. Looking at alphabet flash cards (choice C) may be mentally stimulating but does not address the safety concerns. Watching a cartoon in the activity room (choice D) is a safe and enjoyable activity that can help keep the child entertained without posing a risk of injury or infection.
A nurse is assessing a school-age child who is receiving prednisone. For which of the following adverse effects should the nurse monitor?
- A. Renal failure
- B. Stevens-Johnson syndrome
- C. Prolonged wound healing
- D. Hypotension
Correct Answer: C
Rationale: The correct answer is C: Prolonged wound healing. Prednisone is a corticosteroid that can suppress the immune system and delay wound healing due to its anti-inflammatory effects. The nurse should monitor for this adverse effect by assessing the child's wounds regularly for signs of slow or impaired healing. Renal failure (A) is not a common adverse effect of prednisone. Stevens-Johnson syndrome (B) is a severe skin reaction usually caused by medications but is not typically associated with prednisone. Hypotension (D) is not a common adverse effect of prednisone and is more commonly associated with other medications or conditions.
A nurse is caring for a 1-year-old child who has been hospitalized. Which of the following items in the child's room is a common source of health care-associated infections?
- A. Disposable diapers
- B. Bedside commode
- C. Protective plastic gowns
- D. Unopened bottles of formula
Correct Answer: B
Rationale: The correct answer is B: Bedside commode. This item can harbor bacteria and pathogens if not properly cleaned and sanitized, leading to healthcare-associated infections. Disposable diapers (A) are single-use and unlikely to cause infections. Protective plastic gowns (C) are meant to prevent infections. Unopened bottles of formula (D) are sterile and not a common source of infections.