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A 10-month-old infant
A parent asks a nurse about toys to provide for a 10-month-old infant. Which of the following toys should the nurse suggest?
- A. Coloring book with crayons
- B. Large-piece puzzles
- C. Crib gym
- D. Put-in take-out toy
Correct Answer: C
Rationale: The correct answer is C: Crib gym. At 10 months, infants are developing their motor skills and hand-eye coordination. A crib gym provides visually stimulating objects for the infant to reach for and grab, promoting fine motor skills. Coloring book with crayons (A) is not suitable due to choking hazard. Large-piece puzzles (B) are too advanced for an infant. Put-in take-out toy (D) may also pose a choking risk.
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A child who has iron deficiency anemia
A nurse in a pediatric clinic in caring for a child who has iron deficiency anemia and is to start taking ferrous sulfate syrup. Which of the following Instructions should the nurse give the parent?
- A. Administer the medication at meal time
- B. Administer the medication at bedtime.
- C. Offer the medication through a straw
- D. Dilute the medication with 240 mi. (Bar) of milk
Correct Answer: C
Rationale: The correct answer is C: Offer the medication through a straw. This is because iron supplements can stain teeth, and using a straw can help minimize direct contact with the teeth, reducing the risk of staining. Administering the medication at mealtime (choice A) may cause gastrointestinal upset, and administering it at bedtime (choice B) may increase the risk of staining teeth during sleep. Diluting the medication with milk (choice D) is not recommended as calcium in milk can interfere with iron absorption. Offering the medication through a straw is the best option to ensure effective administration while minimizing side effects.
A child with pneumonia who weighs 20 lb
Primary care provider orders cefazolin (Kefrol) 30 mg/kg in two divided doses per day for a child with pneumonia. Child weighs 20 lb. If the available oral suspension is 125 mg/5ml how many mls per dose should the child receive?
- A. 5.4 mL
Correct Answer: A
Rationale: To calculate the dose, we first convert the child's weight to kg: 20 lb / 2.2 = 9.09 kg. Next, we calculate the total daily dose: 30 mg/kg * 9.09 kg = 272.7 mg/day. Since the dose is divided into 2, each dose is 272.7 mg / 2 = 136.35 mg. To find the volume needed, we divide the dose by the concentration of the suspension: 136.35 mg / 125 mg/5ml = 1.09 ml. However, the dose is divided into two, so each dose is 1.09 ml * 2 = 2.18 ml. Rounded to 1 decimal, the child should receive 2.2 ml per dose, closest to option A: 5.4 ml. Other choices are incorrect as they do not align with the calculated dose.
An adolescent who is having a sickle cell crisis
A nurse is caring for an adolescent who is having a sickle cell crisis. Which of the following nursing actions should the nurse take?
- A. withhold opioids to avoid dependence
- B. Assist RN with administering a blood transfusion
- C. Initiate a 2 L/day fluid restriction
- D. Encourage exercise
Correct Answer: B
Rationale: The correct answer is B: Assist RN with administering a blood transfusion. During a sickle cell crisis, blood transfusions can help improve oxygen delivery to tissues by increasing the number of normal red blood cells. This can help alleviate symptoms and prevent complications. Withholding opioids (choice A) can lead to inadequate pain management. Initiation of fluid restriction (choice C) is inappropriate as hydration is crucial during a sickle cell crisis. Encouraging exercise (choice D) can worsen the crisis by increasing the risk of vaso-occlusive events.
An infant who has developmental dysplasia of the hip (DDH)
A nurse is collecting data from an infant who has developmental dysplasia of the hip (DDH). Which of the following findings should the nurse expect?
- A. Inwardly turned foot on the affected side
- B. Lengthened thigh on the affected side
- C. Absent plantar reflexes
- D. Asymmetric thigh folds
Correct Answer: A,D
Rationale: The correct answers are A and D. In DDH, an inwardly turned foot on the affected side (A) is expected due to hip dislocation. Asymmetric thigh folds (D) are also common as the affected thigh may appear shorter due to dislocation. Lengthened thigh (B) is incorrect as the thigh may appear shortened. Absent plantar reflexes (C) are not typical in DDH.
A client who is postoperative immediately following a tonsillectomy
A nurse is caring for a client who is postoperative immediately following a tonsillectomy. Which of the flowing snacks should the nurse offer the client?
- A. Cranberry juice
- B. Ice-cream
- C. Hot tea
- D. Italian ice
Correct Answer: B,D
Rationale: The correct snacks to offer a client post-tonsillectomy are ice-cream and Italian ice. Ice-cream is soft, cold, and soothing, helping to reduce pain and inflammation. Italian ice is also cold and can provide relief. Cranberry juice and hot tea are acidic and may irritate the surgical site. Ice-cream and Italian ice are the best choices as they are gentle on the throat and provide comfort without causing discomfort.