Nokea
A nursing action that promotes ideal nutrition in an infant with congestive heart failure (CHF) is:
- A. Feeding formula that is supplemented with additional calories.
- B. Allowing the infant to nurse at each breast for 20 minutes.
- C. Providing large feedings every 5 hours.
- D. Using firm nipples with small openings to slow feedings.
Correct Answer: A
Rationale: Supplementing formula with extra calories increases the caloric density to support growth in infants with CHF.
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The following statements are true of bronchiolitis:
- A. Up to 50% of patients continue to wheeze after recovery
- B. The typical pathogen is para-influenza virus
- C. Corticosteroid therapy is beneficial
- D. Tachypnoea is invariable
Correct Answer: A
Rationale: Wheezing after bronchiolitis is common. The typical pathogen is respiratory syncytial virus, not para-influenza. Corticosteroids are not routinely beneficial, and tachypnoea is common but not invariable.
What is the recommended hourly maintenance fluid rate (water) for a 20 kg child?
- A. 50 ml/hour
- B. 60 ml/hour
- C. 80 ml/hour
- D. 100 ml/hour
Correct Answer: B
Rationale: The recommended hourly maintenance fluid rate for a 20 kg child is 60 ml/hour, calculated using the formula: 100 ml/kg for the first 10 kg + 50 ml/kg for the next 10 kg.
The nurse is caring for a child with persistent hypoxia secondary to a cardiac defect. The nurse recognizes that a risk exists of cerebrovascular accidents (strokes). Which is an important objective to decrease this risk?
- A. Minimize seizures
- B. Prevent dehydration
- C. Promote cardiac output
- D. Reduce energy expenditure
Correct Answer: B
Rationale: In children with persistent hypoxia, polycythemia develops. Dehydration must be prevented in hypoxemic children because it potentiates the risk of strokes. Minimizing seizures, promoting cardiac output, and reducing energy expenditure will not reduce the risk of cerebrovascular accidents.
A client who has a history of hypothyroidism was initially admitted with lethargy and confusion. Which additional finding warrants the most immediate action by the nurse?
- A. Facial puffiness and periorbital edema
- B. Hematocrit of 30%
- C. Cold and dry skin
- D. Further decline in level of consciousness
Correct Answer: D
Rationale: A further decline in level of consciousness could indicate myxedema coma, a life-threatening complication of hypothyroidism.
An overweight, young adult made who was recently diagnosed with type 2 diabetes mellitus is admitted for a hernia repair. He tells the nurse that he is feeling very weak and jittery. Which actions should the nurse implement? (Select all that apply.)
- A. Check his fingerstick glucose level
- B. Assess his skin temperature and moisture
- C. Measure his pulse and blood pressure
- D. Document anxiety on the surgical checklist
Correct Answer: C
Rationale: These actions help assess for hypoglycemia, a common issue in diabetic patients, and ensure appropriate intervention.