Nokea
A nurse is reinforcing teaching with an adolescent who has type 1 diabetes mellitus. Which of the following instructions should the nurse include In the teaching?
- A. Inject insulin in the deltoid muscle.
- B. Take glyburide with breakfast.
- C. Obtain an influenza vaccine annually.
- D. Administer glucagon for hyperglycemia.
Correct Answer: C
Rationale: People with diabetes are at higher risk for complications from influenza so annual vaccination is recommended.
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A nurse is collecting data from a 4-year-old child. Which of the following findings should the nurse expect?"
- A. Heart rate 110/min
- B. Capillary refill greater than 3 seconds
- C. Weight gain of 0.9 kg (2 lb) in a year
- D. Respiratory rate 32/min
Correct Answer: A
Rationale: A heart rate of 110 beats per minute is within the normal range for a 4-year-old child. The typical heart rate for this age is between 80 to 120 beats per minute.
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 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.
A nurse is preparing to administer a dexamethasone 1.5 mg/kg/day PO to divide equally every 6 hr to a preschool-age child who weighs 22 lb. Available is dexamethasone oral solution 1 mg/mL. How many mL should the nurse administer per dose? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
- A. 3.8 mL
- B. 2.8 mL
- C. 4.8 mL
- D. 1.8 mL
Correct Answer: 3.8
Rationale: Calculation: 22 lb ÷ 2.2 = 10 kg; 1.5 mg/kg/day × 10 kg = 15 mg/day; 15 mg ÷ 4 doses = 3.75 mg/dose; 3.75 mg × 1 mL/1 mg = 3.8 mL.
A nurse is collecting data from a child who has sickle disease and is experiencing a vaso-occlusive crisis. Which of the following findings should the nurse expect?
- A. Pain
- B. Vomiting
- C. Constipation
- D. Bradycardia
Correct Answer: A
Rationale: Pain is the most common and significant symptom of a vaso-occlusive crisis in sickle cell disease.