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. Which of the following instructions should the nurse give the parent?
- 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: It is not advisable for a parent to attempt to reinsert the tubes if they fall out. This could potentially cause harm to the child's ear. If the tubes fall out, the parent should call the healthcare clinic to report this. The healthcare provider can then decide on the appropriate next steps. It is not accurate to reassure the mother that the tubes will not fall out. Tympanostomy tubes are designed to fall out on their own after a certain period of time. Taking the child to an emergency department is not necessary unless there are signs of infection or other complications.
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Which client on an acute care pediatric unit requires the nurse's immediate attention?
- A. An 18-month-old client who had a cleft palate repair and is crying in pain.
- B. A 12-year-old client who had an appendectomy and refuses to ambulate.
- C. An 8-year-old client who had a tonsillectomy and is swallowing frequently.
- D. A 15-year-old client who has an IV infusion and reports pain at the insertion site.
Correct Answer: C
Rationale: While pain management is important following a cleft palate repair, it does not typically require immediate attention. Pain can be managed with appropriate analgesics and does not typically present an immediate risk to the patient's health. A patient refusing to ambulate following an appendectomy does not typically require immediate attention. Encouraging mobility is important for recovery, but refusal to ambulate does not present an immediate risk to the patient's health. Frequent swallowing following a tonsillectomy could indicate post-operative bleeding, which requires immediate attention. Post-tonsillectomy hemorrhage can be a life-threatening condition that requires immediate intervention. While pain at the site of an IV infusion should be addressed, it does not typically require immediate attention unless there are signs of infection or infiltration. It does not present an immediate risk to the patient's health.
A nurse is caring for a school-age child who has a fracture to the right femur. Which of the following findings is the nurse's priority?
- A. 2+ right pedal pulse
- B. Tingling in the right foot
- C. Capillary refill less than 2 seconds
- D. Respiratory rate 24/min
Correct Answer: B
Rationale: A 2+ right pedal pulse indicates a normal pulse and is not a cause for immediate concern in a child with a femur fracture. Tingling in the right foot could indicate nerve damage or compromised blood flow, which can be a serious complication of a femur fracture. This should be the nurse's priority as it could lead to long-term damage if not addressed promptly. A capillary refill time of less than 2 seconds is considered normal and is not a cause for immediate concern in a child with a femur fracture. A respiratory rate of 24/min is within the normal range for a school-age child and is not a cause for immediate concern in a child with a femur fracture.
A nurse is caring for a child who is having a tonic-clonic seizure and vomiting. Which of the following actions is the nurse's priority?
- A. Place a pillow under the child's head.
- B. Remove the child's eyeglasses.
- C. Time the seizure.
- D. Move the child into a side-lying position.
Correct Answer: D
Rationale: While placing a pillow under the child's head might seem like a good idea, it's actually not recommended during a seizure. The child's movements could be unpredictable, and a pillow could potentially cause suffocation. Removing the child's eyeglasses is a good idea, but it's not the first thing you should do. The child's safety is the top priority, and eyeglasses can be removed once the child is safe. Timing the seizure is important for medical professionals to know, but it's not the first action to take. The child's immediate safety is the priority. Moving the child into a side-lying position is the priority. This position helps keep the airway clear and allows any vomit to exit the mouth, reducing the risk of choking.
A nurse is reinforcing teaching about manifestations of hypoglycemia with an adolescent who has type 1 diabetes mellitus. Which of the following manifestations should the nurse include in the teaching?
- A. Rapid respirations
- B. Diminished reflexes
- C. Acetone breath
- D. Diaphoresis
Correct Answer: D
Rationale: Rapid respirations are not typically a manifestation of hypoglycemia. They are more commonly associated with conditions that cause metabolic acidosis, such as diabetic ketoacidosis. Diminished reflexes are not a typical manifestation of hypoglycemia. They may be seen in conditions affecting the nervous system. Acetone breath is not a manifestation of hypoglycemia. It is a sign of ketoacidosis, which is a complication of hyperglycemia, not hypoglycemia. Diaphoresis, or sweating, is a common symptom of hypoglycemia. The body produces sweat as part of the sympathetic nervous system's response to hypoglycemia.
A nurse is contributing to the plan of care for a 5-week-old infant in the pediatric unit. The infant has been vomiting since week 2 of life and it has been progressively worse over the past 2 weeks. Parents report the vomiting is now forceful and projectile ('like a volcano erupting') immediately after every feeding, but the infant is eager to eat and seems to be constantly hungry. The infant has been receiving a cow's milk-based, iron-fortified formula since birth. The pediatrician reports the infant has not gained weight in the past 2 weeks. The last weight in the pediatrician's office is 3.54kg (8 lb). No other significant medical or surgical history. What condition is the client most likely experiencing and what actions should the nurse take to address that condition? What parameters should the nurse monitor to assess the client's progress?
- A. Gastroesophageal Reflux Disease (GERD), change the formula, monitor weight and feeding habits
- B. Pyloric Stenosis, refer for surgical consultation, monitor weight and vomiting frequency
- C. Lactose Intolerance, switch to lactose-free formula, monitor weight and stool consistency
- D. Milk Protein Allergy, switch to hypoallergenic formula, monitor weight and skin reactions
Correct Answer: B
Rationale: Gastroesophageal Reflux Disease (GERD) in infants is a condition where the stomach contents flow back into the esophagus causing discomfort. However, the symptoms described, such as projectile vomiting and constant hunger, are more consistent with Pyloric Stenosis. Pyloric Stenosis is a condition in infants where the opening from the stomach to the small intestine narrows, preventing food from entering the small intestine. The symptoms described by the parents, such as projectile vomiting after every feeding and constant hunger, align with this condition. The infant's lack of weight gain could be due to the fact that food is not being properly digested and absorbed. The nurse should refer the infant for a surgical consultation as the treatment for Pyloric Stenosis is usually surgical. The nurse should monitor the infant's weight and frequency of vomiting to assess the infant's progress. Lactose Intolerance in infants is a condition where the infant has difficulty digesting lactose, a sugar found in milk and dairy products. Symptoms can include gas, bloating, and diarrhea. However, the symptoms described by the parents do not align with this condition. Milk Protein Allergy in infants is a condition where the infant's immune system reacts negatively to the proteins in cow's milk. Symptoms can include hives, itching, wheezing, difficulty breathing, constipation, and bloody diarrhea. However, the symptoms described by the parents do not align with this condition.