Nokea
A preschool-aged child who is experiencing respiratory distress is brought to the emergency department by the parents. The child is anxious, has a temperature of 102.8° F (39.3° C), and is drooling from the mouth while leaning forward when sitting. Which action should the nurse implement next?
- A. Begin prescribed intravenous antibiotic administration.
- B. Schedule the child for a STAT magnetic resonance imaging (MRI) of the neck.
- C. Obtain bedside trays for intubation or tracheotomy by the healthcare provider.
- D. Provide a nebulizer treatment with bronchodilators.
Correct Answer: C
Rationale: Symptoms suggest epiglottitis, requiring immediate airway management. Intubation/tracheotomy trays are critical to address potential airway obstruction.
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The mother of a 4-month-old baby girl asks the nurse when should she introduce solid foods to her infant. The mother states, 'My mother says I should put rice cereal in the baby's bottle now.' The nurse should instruct the mother to introduce solid foods when her child exhibits which behavior?
- A. Stops rooting when hungry.
- B. Awakens once for nighttime feedings.
- C. Gives up a bottle for a cup.
- D. Opens mouth when food comes her way.
Correct Answer: D
Rationale: Opening the mouth for food, along with head control and sitting support, indicates readiness for solids around 4-6 months.
History and Physical
Nurses Notes
The client is a 4-year-old male with a history of prematurity, short gut syndrome, and liver and bowel transplant. He has been hospitalized for the past 8 months, 6 of those were spent in the pediatric intensive care unit. He is currently in the pediatric unit for observation as his post transplant medications are stabilized for discharge.
Which action(s) is/are appropriate for the nurse caring for this child? Select all that apply.
- A. Avoid mentioning anything about the mother to the child.
- B. Develop a trusting relationship with the child.
- C. Notify the mother that social services will be notified if she does not visit regularly.
- D. Have the child sign a treatment contract stating he will participate in therapy.
- E. Ask the mother to bring a familiar object from home.
- F. Facilitate phone conversations between the child and his mother.
Correct Answer: B,E,F
Rationale: Building trust, providing familiar objects, and facilitating mother-child communication support the child's emotional well-being during hospitalization.
Based on the assessment findings, the priority diagnosis suspected is... This diagnosis places the client at risk of...
- A. Mastitis
- B. Engorgement
- C. Blocked milk duct
- D. Inflammatory breast cancer
- E. Abscess
- F. Breastfeeding intolerance
- G. Nipple thrush
Correct Answer: A
Rationale: Mastitis, indicated by fever, localized breast symptoms, and systemic signs, is the priority diagnosis. It risks progressing to an abscess if untreated, requiring prompt intervention.
History and Physical
Nurses' Notes
Orders
The client is a 4-month-old female with a history of gastroesophageal reflux (GERD). Client had fundoplication surgery and will be hospitalized for several days of recovery.
Which are the 3 most likely reasons that the infant is crying?
- A. Hunger
- B. Opioid withdrawal
- C. Hemorrhage
- D. Separation anxiety
- E. Pain
- F. Hypovolemia
- G. Hypoxia
Correct Answer: A,E,F
Rationale: Hunger due to NPO status, postoperative pain, and hypovolemia from surgical fluid losses are likely causes of crying. No evidence supports withdrawal, hemorrhage, anxiety, or hypoxia.
Albumin 25% IV is prescribed for a child with nephrotic syndrome. Which assessment finding indicates to the nurse that the medication is having the desired effect?
- A. Weight gain.
- B. Reduction of edema.
- C. Improved caloric intake.
- D. Reduction of fever.
Correct Answer: B
Rationale: Albumin increases oncotic pressure, reducing edema by drawing fluid back into circulation in nephrotic syndrome.