Nokea
A nurse is providing teaching about the administration of gastrostomy tube feedings to the parents of a school-age child. Which of the following instructions should the nurse include?
- A. Administer the feeding over 30 min.
- B. Change the feeding bag and tubing every 3 days.
- C. Place the child in a supine position after the feeding.
- D. Warm the formula in the microwave prior to administration.
Correct Answer: A
Rationale: The correct answer is A: Administer the feeding over 30 min. This instruction is important to prevent complications such as aspiration and dumping syndrome. Administering the feeding slowly over 30 minutes allows for proper digestion and absorption. Choice B is incorrect because feeding bags and tubing should be changed every 24 hours to prevent bacterial growth. Choice C is incorrect because the child should be placed in an upright position, not supine, after the feeding to reduce the risk of aspiration. Choice D is incorrect because warming formula in the microwave can create hot spots and lead to burns.
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A nurse in an emergency department is caring for a 3-year-old child who has suspected epiglottitis. Which of the following actions should the nurse take?
- A. Prepare to assist with intubation.
- B. Obtain a throat culture.
- C. Suction the child's oropharynx.
- D. Prepare a cool mist tent.
Correct Answer: A
Rationale: The correct answer is A: Prepare to assist with intubation. Epiglottitis is a medical emergency where the epiglottis becomes inflamed and can lead to airway obstruction. Intubation may be necessary to secure the airway and ensure the child can breathe. It is a priority action to maintain the child's oxygenation and ventilation. Obtaining a throat culture (B) can be important for diagnosis but is not the immediate priority. Suctioning the child's oropharynx (C) can trigger a spasm and worsen the obstruction. Cool mist tent (D) is not indicated in the management of epiglottitis.
A nurse is assessing a child who has measles. Which of the following areas should the nurse inspect for Koplik spots?
Correct Answer: C
Rationale: The correct answer is C. Koplik spots are small, white, grain-like spots with a red halo that appear on the buccal mucosa opposite the molars. They are specific to measles and typically appear 2-4 days before the rash. Inspecting other areas like the skin (choice A), scalp (choice B), nails (choice D), ears (choice E), throat (choice F), or feet (choice G) would not reveal Koplik spots as they are only found in the mouth. Therefore, choice C is the correct option for assessing Koplik spots in a child with measles.
A nurse is assessing the fontanels of an infant. Which of the following findings should the nurse recognize as an expected finding?
- A. The posterior fontanel is open.
- B. The anterior fontanel is open.
- C. Both fontanels are the same size.
- D. Both fontanels show molars.
Correct Answer: B
Rationale: The correct answer is B: The anterior fontanel is open. The anterior fontanel is typically open in infants to allow for brain growth and development. It is a normal finding during infancy and should close by around 18 months of age. Choice A is incorrect because the posterior fontanel closes shortly after birth. Choice C is incorrect because the fontanels are not expected to be the same size; the anterior fontanel is larger than the posterior fontanel. Choice D is incorrect because the presence of molars in the fontanels would not be expected and could indicate a medical issue.
The nurse is continuing to care for the child. Select the 3 priority actions that the nurse should take.
- A. Review cast care instructions with the child's parents
- B. Administer ibuprofen 200 mg PO
- C. Place a nonadherent dressing on the right knee abrasion.
- D. Explain the cast application procedure to the child.
- E. Apply ice packs to the fingers and along the right forearm.
- F. Elevate the affected forearm with pillows.
Correct Answer: A,B,F
Rationale: The correct answers are A, B, and F. A) Reviewing cast care instructions with the child's parents ensures proper care at home. B) Administering ibuprofen helps manage pain and inflammation. F) Elevating the affected forearm reduces swelling. Choices C, D, and E are incorrect because C) placing a nonadherent dressing is not a priority over cast care, D) explaining cast application to the child is not essential for ongoing care, and E) applying ice packs to fingers and forearm is not as crucial as administering pain relief and elevating the affected area.
A nurse is assessing a child who has bacterial pneumonia. Which of the following manifestations should the nurse expect?
- A. Steatorrhea
- B. Fever
- C. Drooling
- D. Tinnitus
Correct Answer: B
Rationale: The correct answer is B: Fever. In bacterial pneumonia, the body's immune response leads to fever as a common manifestation due to the infection. This is because the body is trying to fight off the bacterial invasion. Steatorrhea (A) is not typically associated with bacterial pneumonia. Drooling (C) is more commonly seen in conditions affecting the mouth or throat. Tinnitus (D) is a symptom related to the ears and is not typically associated with pneumonia. Therefore, the presence of fever is the most relevant sign in a child with bacterial pneumonia.