Nokea
A nurse is preparing a 4-year-old child for discharge following a bilateral myringotomy with tympanostomy tube placement. The mother asks what to do if the tubes fall out. The nurse should give the parent which of the following instructions?
- A. Gently reinsert the tubes.
- B. Call the health care clinic to report that the tubes have fallen out.
- C. Reassure the mother that the tubes will not fall out.
- D. Take the child to an emergency department.
Correct Answer: B
Rationale: The healthcare provider needs to be informed to assess if new tubes are necessary.
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A nurse is reinforcing teaching with an adolescent who has type 1 diabetes mellitus. Which of the following instructions should the nurse include In the teaching?
- A. Inject insulin in the deltoid muscle.
- B. Take glyburide with breakfast.
- C. Obtain an influenza vaccine annually.
- D. Administer glucagon for hyperglycemia.
Correct Answer: C
Rationale: People with diabetes are at higher risk for complications from influenza so annual vaccination is recommended.
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. Temporal
- B. Carotid
- C. Apical
- D. Dorsalis pedis
Correct Answer: C
Rationale: The apical pulse is the most reliable method for assessing heart rate in infants.
A nurse is collecting data from an infant who has a large patent ductus arteriosus. Which of the following is clinical manifestations should the nurse expect?
- A. Cyanosis with crying
- B. Weak pulses
- C. Chronic hypoxemia
- D. Machine-like murmur
Correct Answer: D
Rationale: A characteristic feature of PDA is a continuous
A nurse is caring for an infant who is dehydrated and requires IV therapy. The nurse should monitor the infant's response to therapy by performing which of the following actions?
- A. Taking the infant's vital signs every 2 hr
- B. Counting the number of wet diapers every shift
- C. Weighing the infant at the same time every day
- D. Measuring the infant's head circumference twice per day
Correct Answer: C
Rationale: Daily weights are a critical measure of fluid balance in infants. A consistent daily weight check provides a direct and accurate assessment of the infant's hydration status and response to IV therapy.
A nurse is teaching the parents of a child who has diabetes mellitus about the manifestations of hypoglycemia. Which of the following manifestations should the nurse include in the teaching?
- A. Fruity breath odor
- B. Diaphoresis
- C. Dry mucous membranes
- D. Polyuria
Correct Answer: B
Rationale: Diaphoresis is a common symptom of hypoglycemia due to the activation of the sympathetic nervous system.