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A 3-month-old infant receiving oral elixir
A nurse is preparing to administer an oral elixir to a 3-month-old infant using an oral medication syringe. Which of the following actions should the nurse plan to take?
- A. Measure the elixir in a medicine cup before transferring to a syringe
- B. Place the infant supine in a crib prior to administration.
- C. Position the syringe to the side of the infant's tongue.
- D. Mix the medication with 10 mL of formula.
Correct Answer: C
Rationale: The correct answer is C: Position the syringe to the side of the infant's tongue. This is the correct action as it helps prevent choking and aspiration in infants. Placing the syringe to the side allows the infant to swallow the medication more effectively while reducing the risk of it going down the wrong pipe. It also encourages a natural swallowing reflex.
Choice A is incorrect because measuring in a medicine cup before transferring to a syringe may lead to inaccuracies in dosage. Choice B is incorrect as placing the infant supine increases the risk of choking. Choice D is incorrect as mixing medication with formula may interfere with the medication's effectiveness.
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A child with asthma who weighs 4.69 kg
A child with asthma has the following medication ordered: Theophylline 4 mg/kg/dose every 6 hrs. The child weighs 4.69 kg. Calculate the appropriate dose.
- A. 33.6 mg
- B. 18.7 mg
- C. 8.4 mg
- D. 19 mg
Correct Answer: B
Rationale: To calculate the appropriate dose for the child, we first need to determine the child's weight in mg: 4.69 kg x 4 mg/kg = 18.76 mg. Since the dose is rounded to the nearest tenth, the correct dose is 18.7 mg (choice B). This calculation ensures the child receives the correct amount of medication based on their weight. Choices A, C, and D are incorrect as they do not accurately reflect the calculated dose.
A 4-year-old child who is 2 days postoperative following the insertion of a ventriculoperitoneal shunt
A nurse is caring for a 4-year-old child who is 2 days postoperative following the insertion of a ventriculoperitoneal shunt. Which of the following findings should the nurse identify as the priority?
- A. Lethargy
- B. Urine output 70 mL in 2 hr
- C. Lying flat on the unaffected side
- D. Respiratory rate 20/min
Correct Answer: A
Rationale: The correct answer is A: Lethargy. Following a ventriculoperitoneal shunt insertion, lethargy in a child could indicate increased intracranial pressure, a potentially life-threatening complication. The priority is to assess for signs of neurological deterioration promptly. Urine output (B) is important but not as urgent as assessing neurological status. Lying flat on the unaffected side (C) is not a priority; positioning can be adjusted later. Respiratory rate (D) within normal range is reassuring but not the priority in this case.
A child who has hemophilia
A nurse is reinforcing teaching about controlling a bleeding episode with a parent of a child who has hemophilia. Which of the following statements by the parent indicates a need for further teaching?
- A. I will elevate the affected area if possible.
- B. I will apply warm compresses over the site.
- C. I will have my child rest.
- D. I will promptly immobilize the involved area to relieve pain & decrease bleeding.
Correct Answer: B
Rationale: The correct answer is B because applying warm compresses can worsen bleeding in hemophilia by dilating blood vessels. Elevating the affected area helps reduce blood flow to the site, aiding in clot formation. Resting minimizes movement that could exacerbate bleeding. Promptly immobilizing the area helps reduce pain and prevent further bleeding. Therefore, the incorrect choice (B) contradicts the principles of managing bleeding in hemophilia.
A preschool age child undergoing endotracheal suctioning
A charge nurse is observing a newly licensed nurse who is performing endotracheal suctioning for a preschool age child. Which of the following actions by the newly licensed nurse requires the charge nurse to intervene?
- A. Applying suction for 20 seconds
- B. Introducing the catheter without suction
- C. Rotating the catheter between the thumb and forefinger while suctioning
- D. Allowing the child to rest for 30 to 60 seconds between suctioning passes
Correct Answer: B
Rationale: The correct answer is B: Introducing the catheter without suction. When performing endotracheal suctioning, it is crucial to apply suction while introducing the catheter to effectively remove secretions. Introducing the catheter without suction can result in ineffective suctioning and potential harm to the child.
A: Applying suction for 20 seconds is within the recommended time frame for suctioning.
C: Rotating the catheter while suctioning helps to ensure thorough removal of secretions.
D: Allowing the child to rest between suctioning passes is important to prevent hypoxia and maintain oxygenation.
In summary, choice B is incorrect because it goes against the fundamental principle of effective suctioning, while choices A, C, and D are all appropriate actions during endotracheal suctioning for a preschool-age child.
A 10-month-old infant
A parent asks a nurse about toys to provide for a 10-month-old infant. Which of the following toys should the nurse suggest?
- A. Coloring book with crayons
- B. Large-piece puzzles
- C. Crib gym
- D. Put-in take-out toy
Correct Answer: C
Rationale: The correct answer is C: Crib gym. At 10 months, infants are developing their motor skills and hand-eye coordination. A crib gym provides visually stimulating objects for the infant to reach for and grab, promoting fine motor skills. Coloring book with crayons (A) is not suitable due to choking hazard. Large-piece puzzles (B) are too advanced for an infant. Put-in take-out toy (D) may also pose a choking risk.