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A nurse is reinforcing teaching about methylphenidate (Ritalin) with the parents of a school-age child who has ADHD. Which of the following instructions should the nurse include?
- A. You should give your child's last daily dose of the medication before 6 o'clock in the evening.
- B. You will need to give your child the medication after meals.
- C. You will need to have your child's blood glucose level checked monthly.
- D. You should not give your child the medication on weekends.
Correct Answer: A
Rationale: Methylphenidate is a stimulant and giving it too late in the day can cause insomnia.
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A nurse is teaching the parents of a child who has diabetes mellitus about the manifestations of hypoglycemia. Which of the following manifestations should the nurse include in the teaching?
- A. Fruity breath odor
- B. Diaphoresis
- C. Dry mucous membranes
- D. Polyuria
Correct Answer: B
Rationale: Diaphoresis is a common symptom of hypoglycemia due to the activation of the sympathetic nervous system.
A nurse is contributing to the plan of care for a school-age child who has moderate partial-thickness burns on both lower extremities. Which of the following interventions should the nurse include?
- A. Maintain medical asepsis during dressing changes.
- B. Administer pain medication 30 min to 1 hour before physical therapy.
- C. Allow the child to set her own schedule for care.
- D. Provide low-calorie snacks.
Correct Answer: B
Rationale: Pain management is crucial to facilitate participation in physical therapy and improve outcomes.
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. Capillary refill less than 2 seconds
- B. Tingling in the right foot
- C. 2+ right pedal pulse
- D. Respiratory rate 24/min
Correct Answer: B
Rationale: Tingling (paraesthesia) can be a sign of nerve damage or compromised circulation which may indicate complications such as compartment syndrome. This is a priority finding because it can lead to severe consequences if not addressed promptly.
A nurse is collecting data from an infant. Which of the following sites is the most reliable location to check the infant's pulse?
- A. Temporal
- B. Carotid
- C. Apical
- D. Dorsalis pedis
Correct Answer: C
Rationale: The apical pulse is the most reliable method for assessing heart rate in infants.
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.