Nokea
A nurse working at a clinic speaks on the telephone with a parent of a 2-month-old infant. The parent tells the nurse that the infant has projectile vomiting followed by hunger after meals. Which of the following responses by the nurse is appropriate?
- A. Bring your infant into the clinic today to be seen.
- B. You might want to try switching to a different formula.
- C. Give your infant an oral rehydration solution.
- D. Burp your child more frequently during feedings.
Correct Answer: A
Rationale: Projectile vomiting can be a sign of pyloric stenosis a condition that requires prompt medical evaluation.
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A nurse is caring for a 6-month-old child. The child's provider has ordered a diphtheria, tetanus, and pertussis (DTaP) vaccine to be administered. Which of the following should cause the nurse to question the administration of this vaccine?
- A. New onset of seizure disorder in the child's sibling
- B. Evidence of sensitivity to egg antigens
- C. Afebrile otitis media
- D. Temperature of 40.5° C (104.9° F) after last DTaP
Correct Answer: D
Rationale: A high fever following a previous dose of DTaP may indicate a severe reaction.
A nurse is caring for an adolescent following the application of a plaster cast for a fractured right tibia. Which of the following actions should the nurse take?
- A. Keep the client's leg in a dependent position.
- B. Use a hair dryer on a hot setting to dry the cast.
- C. Discourage the client from ambulating.
- D. Perform a neurovascular check of the lower extremities.
Correct Answer: D
Rationale: Neurovascular checks are essential to ensure that there is adequate blood flow and nerve function below the cast.
A nurse is caring for a child who is experiencing an acute asthma attack. Which of the following medications should the nurse administer first?
- A. Methylprednisolone
- B. Montelukast
- C. Albuterol
- D. Fluticasone
Correct Answer: C
Rationale: Albuterol is a short-acting beta-agonist that provides rapid bronchodilation. It is the first-line medication for immediate relief of bronchospasm during an acute asthma attack.
A nurse in a family health clinic is collecting data as part of a routine physical examination of a client who is about to enter high school. The nurse observes an abnormal lateral curvature of the spine. The nurse should expect the provider to document which of the following disorders?
- A. Scoliosis
- B. Ankylosis
- C. Kyphosis
- D. Lordosis
Correct Answer: A
Rationale: Scoliosis is characterized by an abnormal lateral curvature of the spine.
A nurse is preparing to administer amoxicillin 350 mg PO. The amount available is amoxicillin oral solution 250 mg/5 mL. How many ml. should the nurse administer? (Round the answer to the nearest tenth/whole number. Use a leading zero if it applies. Do not use a trailing zero.)
- A. 7 mL
- B. 6 mL
- C. 8 mL
- D. 5 mL
Correct Answer: 7
Rationale: Formula: Volume to administer=Desired dose/Available dose ×Volume available. Calculation: 350 mg/250 mg × 5 mL=7 mL.