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A nurse is reinforcing teaching with the parent of a preschooler who has amblyopia. Which of the following instructions should the nurse include in the teaching?
- A. Instill two drops of antibiotic eye solution into both eyes for 14 days.
- B. Irrigate both eyes with sterile water twice daily.
- C. Patch the unaffected eye during the day.
- D. Apply a warm pack to the affected eye three to four times per day.
Correct Answer: C
Rationale: Patching the unaffected eye strengthens the affected eye in amblyopia. Antibiotics, irrigation, or warm packs are not treatments for this condition.
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A nurse is collecting data from a 5-month-old infant who is postoperative following umbilical hernia repair. Which of the following measures should the nurse use to evaluate the infant's pain level?
- A. FLACC pain rating scale
- B. COMFORT pain rating scale
- C. FACES pain rating scale
- D. CRIES pain rating scale
Correct Answer: A
Rationale: FLACC is ideal for non-verbal infants post-surgery. COMFORT suits ICU settings, FACES is for older children, and CRIES is for neonates up to 6 months.
A nurse is contributing to the plan of care for a child who has nephrotic syndrome and a prescription for corticosteroids. Which of the following interventions should the nurse recommend?
- A. Provide a low-sodium diet.
- B. Encourage increased fluid intake.
- C. Obtain urine ketone levels weekly.
- D. Administer pancreatic enzymes with each meal.
Correct Answer: A
Rationale: A low-sodium diet manages fluid retention in nephrotic syndrome. Increased fluids worsen edema, urine ketones are irrelevant, and pancreatic enzymes are not indicated.
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.
A nurse is obtaining a sputum sample from a school-age child. Which of the following actions should the nurse take?
- A. Ask the child to cough deeply.
- B. Ask the child to clear their throat.
- C. Use wall suction to obtain the sample from the child's throat.
- D. Use a bulb syringe to obtain sputum from the child's mouth.
Correct Answer: A
Rationale: Asking the child to cough deeply helps obtain a sputum sample from the lower respiratory tract. Clearing the throat, wall suction, or bulb syringe are less effective or inappropriate methods.
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.