Nokea
A one-month-old patient, who has developmental dysplasia of the hip, is placed in a hip spica cast. The patient's mother expresses the desire to continue breastfeeding. What is the pediatric nurse's best response?
- A. After breastfeeding, hold your baby upright for 45 minutes.
- B. Due to the weight of the cast, breastfeeding is not encouraged. I recommend that you bottle-feed.
- C. Breastfeeding can continue without significant changes; ensure proper positioning to accommodate the cast.
- D. none of the above.
Correct Answer: C
Rationale: Breastfeeding can continue even with a hip spica cast, but proper positioning is essential to ensure comfort for both the infant and the mother.
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The child begins to understand right and left by age of
- A. 3 yr
- B. 4 yr
- C. 5 yr
- D. 6 yr
Correct Answer: C
Rationale: Understanding right and left typically develops around age 5.
Which of the following malignant tumors is least likely to occur in adults in comparison with children?
- A. acute Lymphoblastic Leukemia (ALL)
- B. osteosarcoma
- C. medulloblastoma
- D. retinoblastoma
Correct Answer: D
Rationale: Retinoblastoma predominantly occurs in children under 5 years of age, making it the least likely to occur in adults.
An adult is receiving total parenteral nutrition. The nurse knows which of the following assessments is essential?
- A. Evaluation of the peripheral venous site
- B. Confirmation that the tube is in the stomach
- C. Assessment of the GI tract, including bowel sounds
- D. Fluid and electrolyte monitoring
Correct Answer: D
Rationale: For an adult receiving total parenteral nutrition (TPN), it is essential for the nurse to monitor fluid and electrolyte levels closely. TPN provides all essential nutrients, including fluids and electrolytes, directly into the bloodstream. Monitoring these levels is crucial to prevent potential complications such as fluid overload, electrolyte imbalances, and hyperglycemia. Assessing and maintaining appropriate fluid and electrolyte balance are essential components of managing a patient receiving TPN to ensure optimal patient outcomes.
Which organ(s) is/are most at risk for dysfunction in a patient with a potassium level of 6.3 mEq/L?
- A. Lungs
- B. Liver
- C. Kidneys
- D. Heart
Correct Answer: D
Rationale: A potassium level of 6.3 mEq/L indicates hyperkalemia, which can have significant effects on the heart. The heart is one of the most sensitive organs to changes in potassium levels. In hyperkalemia, elevated serum potassium levels can lead to various cardiac manifestations, including dysrhythmias, conduction abnormalities, and eventually cardiac arrest. Monitoring and managing potassium levels are crucial in preventing life-threatening cardiac complications in patients with hyperkalemia. While the kidneys and other organs can also be affected by high potassium levels, the heart is the most critical organ to consider in this scenario.
What are the signs of organ rejection a nurse should closely monitor for when caring for a client after heart transplantation? Choose all that apply
- A. Low white blood cell count
- B. Dyspnea
- C. ECG changes
- D. Fever
Correct Answer: A
Rationale: When caring for a client after heart transplantation, the signs of organ rejection that a nurse should closely monitor for include low white blood cell count and dyspnea.