A nurse is preparing to administer acetaminophen 15 mg/kg PO to a preschool child for fever. The child weighs 30 lb. Available is acetaminophen liquid 160 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
- A. 6.4 mL
- B. 5.4 mL
- C. 7.4 mL
- D. 4.4 mL
Correct Answer: 6.4
Rationale: Calculation: 30 lb × 0.454 kg/lb = 13.62 kg; 15 mg/kg × 13.62 kg = 204.3 mg; 204.3 mg ÷ 160 mg/5 mL = 6.4 mL.
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A nurse is caring for a child who is experiencing an acute asthma attack. Which of the following medications should the nurse administer first?
- A. Methylprednisolone
- B. Montelukast
- C. Albuterol
- D. Fluticasone
Correct Answer: C
Rationale: Albuterol is a short-acting beta-agonist that provides rapid bronchodilation. It is the first-line medication for immediate relief of bronchospasm during an acute asthma attack.
A nurse is preparing to administer ear drops to a 2-year-old toddler who has an ear infection and a small amount of purulent drainage visible around the ear. Which of the following techniques should the nurse use when instilling the medication?
- A. Firmly push a cotton ball into the ear canal after instilling drops.
- B. Pull the child's ear auricle upward and outward just before instilling drops.
- C. Apply clean gloves and clean the outer ear prior to instilling drops.
- D. Warm the medication container for 10 seconds in a microwave oven prior to installation.
Correct Answer: C
Rationale: Applying clean gloves and cleaning the outer ear is essential for preventing infection and ensuring that the medication is administered properly. This is a standard procedure to maintain hygiene.
A nurse on a medical-surgical unit is caring for a group of children. Which of the following findings should alert the nurse that one of the children is a potential victim of abuse?
- A. A school-age child who cries when the nurse is giving him an injection
- B. A toddler who has multiple bruises on the shins of both legs and his parents report that he is clumsy
- C. A preschooler who has a BMI indicating obesity
- D. An adolescent who asks to stay in the hospital because he likes the room
Correct Answer: D
Rationale: This might indicate that the adolescent is not feeling safe or comfortable at home which could be a sign of abuse or neglect.
A nurse is collecting data from a 5-month-old infant who has increased intracranial pressure (ICP) resulting from hydrocephalus. Which of the following manifestations should the nurse expect?
- A. Low-pitched cry
- B. Positive Babinski reflex
- C. Insomnia
- D. Bulging fontanel
Correct Answer: D
Rationale: A bulging fontanel is a key sign of increased ICP in infants. It occurs due to pressure within the skull causing the soft spot on the head to protrude.
A nurse is caring for an 8-month-old infant who is receiving intravenous (IV) fluids via a 24-gauge catheter. Which of the following statements by the client's mother indicates that the nurse should check the site for signs of infiltration?
- A. My baby's fingers are looking swollen.
- B. The tape is coming off the IV needle.
- C. There's blood backing up my baby's IV tubing.
- D. There's a long red streak up my baby's arm.
Correct Answer: A
Rationale: Swelling around the IV site can indicate infiltration where IV fluids leak into surrounding tissues.
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