Nokea
A nurse is reinforcing teaching with an assistive personnel (AP) about counting the respiratory rate for a 1-month-old infant. Which of the following statements by the AP indicates an understanding of the teaching?
- A. I will immediately report irregular respirations.
- B. I will immediately report a respiratory rate of 28.
- C. I will count the baby's respirations for 30 seconds and multiply by two.
- D. I will count the baby's respirations by observing abdominal movements.
Correct Answer: D
Rationale: In infants respiration is primarily diaphragmatic making abdominal movements a reliable indicator of respiratory rate.
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A nurse is caring for a client who is postoperative immediately following a tonsillectomy. Which of the following snacks should the nurse offer the client?
- A. Lime ice pop
- B. Cranberry juice
- C. Ice cream
- D. Hot tea
Correct Answer: A
Rationale: A lime ice pop is a good option because it is cold soothing and less likely to irritate the throat or cause bleeding. The cold temperature can help reduce swelling and provide comfort.
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.
An adolescent was recently diagnosed with acne vulgaris and was prescribed tetracycline. Which of the following statements indicates that the client requires further education?
- A. I'll take this medication at least an hour before I eat a meal
- B. I'll take this medication with a full glass of milk
- C. I'll take this medication with a full glass of water on an empty stomach
- D. I'll stay out of direct sunlight while taking this medication
Correct Answer: B
Rationale: Tetracycline should not be taken with dairy products including milk because calcium in dairy can bind to the antibiotic and significantly reduce its absorption.
A nurse is assisting with the care of a school-age child who has respiratory failure due to pneumonia. Which of the following positions should the nurse encourage to allow maximal lung expansion?
- A. Supine
- B. Prone
- C. Upright
- D. Side-lying
Correct Answer: C
Rationale: Sitting upright or in a high Fowler's position is optimal for lung expansion.
A nurse is caring for a 4-year-old child who has dehydration. Which of the following findings should the nurse identify as the priority?
- A. Sodium 142 mEq/L
- B. Urine specific gravity 1.025
- C. Potassium 2.5 mEq/L
- D. Blood glucose 110 mg/Dl
Correct Answer: C
Rationale: Potassium 2.5 mEq/L is below the normal range for potassium (3.5-5.0 mEq/L) and indicates hypokalemia which can cause serious cardiac issues and muscle weakness.