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A nurse is reinforcing teaching with the guardian of a 1-month-old infant who has colic. Which of the following instructions should the nurse include in the teaching?
- A. Offer a pacifier when your baby is fussy.
- B. You should offer water in between feedings.
- C. You should place a warm heating pad on your baby's abdomen.
- D. Allow your baby to cry for 5 minutes before responding.
Correct Answer: A
Rationale: A pacifier soothes colicky infants. Water risks intoxication, heating pads may burn, and delayed response increases distress in young infants.
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A nurse is assisting with the care of a child who is in status asthmaticus. Which of the following medications should the nurse administer first?
- A. Heliox via inhalation
- B. Albuterol via nebulizer
- C. Prednisone by mouth
- D. 0.9% sodium chloride via IV bolus
Correct Answer: B
Rationale: Albuterol rapidly relieves bronchospasm in status asthmaticus. Heliox, prednisone, and saline are secondary or not indicated as first-line treatments.
A nurse is reinforcing teaching with the parents of a preschooler who has recently started to stutter. Which of the following instructions should the nurse include?
- A. Critique your child's speech.
- B. Look away from your child when they start to stutter.
- C. Avoid completing your child's sentences.
- D. Tell your child to take a deep breath when they are stuttering.
Correct Answer: C
Rationale: Avoiding sentence completion reduces pressure and supports fluency. Critiquing, looking away, or suggesting deep breaths may increase anxiety and worsen stuttering.
A nurse is reinforcing teaching with a school-age child who has mild persistent asthma and has a new prescription for therapy with montelukast. Which of the following information should the nurse include?
- A. This medication helps prevent bronchospasms.
- B. This medication is a corticosteroid.
- C. You should take this medication for an acute asthma attack.
- D. You should take this medication first thing in the morning.
Correct Answer: A
Rationale: Montelukast prevents bronchospasms by reducing airway inflammation. It is not a corticosteroid, not for acute attacks, and is typically taken in the evening.
A nurse is preparing to obtain a blood pressure reading from a school-age child. Which of the following actions should the nurse take?
- A. Record the diastolic value as the first Korotkoff sound (K1).
- B. Release the cuff pressure at a rate of about 5 mm Hg/second.
- C. Position the child's arm at the level of the heart.
- D. Select a cuff with a bladder size that is approximately 20% of the child's upper arm circumference.
Correct Answer: C
Rationale: Positioning the arm at heart level ensures accuracy. Diastolic is K5, cuff release should be 2-3 mm Hg/second, and cuff size is ~40% of arm circumference.
A nurse is collecting data from a toddler who has heart failure. Which of the following findings should the nurse expect?
- A. Weight loss of 0.9 kg (2 lb)
- B. Heart rate 65/min
- C. Bounding peripheral pulses
- D. Decreased urine output
Correct Answer: D
Rationale: Decreased urine output is expected in heart failure due to poor renal perfusion. Weight gain, not loss, is typical, and heart rate is usually elevated, not normal. Pulses are often weak.