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A nurse is reinforcing discharge teaching about preventing infections with the parent of a child who is receiving chemotherapy and has a platelet count of 100,000/mm3. Which of the following statements by the parent indicates an understanding of the teaching?
- A. I will take my child's rectal temperature daily to ensure the most accurate reading.
- B. I will make sure my child receives the MMR vaccine by the end of the week.
- C. I will take my child to the park to ride her new bike.
- D. I will inspect the inside of my child's mouth for sores every day.
Correct Answer: D
Rationale: Inspecting the mouth for sores detects mucositis early, reducing infection risk. Rectal temperatures, live vaccines like MMR, and park visits increase infection risk during chemotherapy.
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A nurse is assisting in the admission of a 9-month-old infant who has gastroenteritis with vomiting and diarrhea. Which of the following findings is the nurse's priority?
- A. Skin turgor
- B. Potassium level
- C. Capillary refill
- D. Heart rate
Correct Answer: D
Rationale: The elevated heart rate (tachycardia) at 182/min indicates increased cardiac workload, likely due to dehydration from gastroenteritis, requiring immediate attention. While skin turgor, potassium levels, and capillary refill are important, tachycardia is the priority to stabilize the infant.
A nurse is reinforcing teaching with the guardian of an adolescent who has ADHD and a prescription for methylphenidate. Which of the following statements by the guardian indicates an understanding of the teaching?
- A. I will expect my child to gain weight while taking the medication.
- B. I will use charts to assist my child with organizing their day.
- C. I will alternate my child's study area weekly.
- D. I will give my child the medicine when they need it.
Correct Answer: B
Rationale: Using charts supports organization in ADHD. Methylphenidate may cause weight loss, changing study areas disrupts routine, and it requires regular dosing, not as-needed.
A nurse in a clinic is caring for a group of infants. Which of the following findings should the nurse report as a possible indication of physical maltreatment?
- A. A hemangioma on the infant's torso
- B. A burn with splash marks on the lower right leg
- C. A large, irregular, brownish-blue area on the infant's buttock
- D. An abrasion on the back of the infant's arm
Correct Answer: B
Rationale: Splash-mark burns suggest possible abuse due to their pattern and should be reported. Hemangiomas are benign, bruises need context, and abrasions may be accidental.
A nurse is caring for a preschooler immediately following the application of a long-leg plaster cast due to a fracture. Which of the following actions is the nurse's priority?
- A. Monitor capillary refill of the casted extremity.
- B. Use the palms of the hands when supporting the cast.
- C. Examine the skin at the cast edges.
- D. Instruct the child not to put anything inside the cast.
Correct Answer: A
Rationale: Monitoring capillary refill is critical to assess circulation and detect complications like compartment syndrome post-cast application. Supporting the cast, checking skin, and instructing the child are important but secondary to ensuring circulation.
A nurse is collecting data from a 1-month-old infant who has just undergone a hernia repair. Which of the following findings should the nurse report to the provider?
- A. Axillary temperature 37.4° C (99.3° F)
- B. Apical pulse 155/min
- C. Respiratory rate 40/min
- D. Blood pressure 64/40 mm Hg
Correct Answer: D
Rationale: Blood pressure of 64/40 mm Hg is abnormally low, indicating potential shock or dehydration, requiring immediate reporting. Other findings are within normal ranges for a 1-month-old.