Nokea
A recent history of which of the following should alert the nurse to gather additional information about the possibility of a urinary tract infection in a 2-year-old child who is exhibiting fever and fussiness?
- A. Abdominal pain.
- B. Swollen lymph glands.
- C. Skin rash.
- D. Back pain.
Correct Answer: A
Rationale: Abdominal pain can indicate UTI.
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When developing the plan of care for a child diagnosed with phenylketonuria (PKU), the nurse should establish which of the following goals?
- A. Meeting the child's nutritional needs for optimal growth.
- B. Ensuring that the special diet is started at age 3 weeks.
- C. Permitting serum phenylalanine level higher than 12 mg/100 mL.
- D. Maintaining serum phenylalanine level lower than 2 mg/100 mL.
Correct Answer: A
Rationale: The goal is to meet nutritional needs via a phenylalanine-restricted diet for growth while preventing neurological damage. The diet starts at diagnosis, not 3 weeks, and phenylalanine levels should be 2-6 mg/100 mL.
A nasogastric tube is ordered to be inserted for a child with severe head trauma. Diagnostic testing reveals that the child has a basilar skull fracture. What should the nurse do next?
- A. Ask for the order to be changed to oral gastric tube.
- B. Attempt to place the tube into the duodenum.
- C. Test the gastric aspirate for blood.
- D. Use extra lubrication when inserting the nasogastric tube.
Correct Answer: A
Rationale: Basilar skull fractures contraindicate NG tube insertion due to the risk of cranial penetration; an oral gastric tube is safer.
The nurse is assessing a neonate with suspected tracheoesophageal fistula. Which of the following findings would be most concerning?
- A. Excessive drooling.
- B. Mild cyanosis during feeding.
- C. Heart rate of 140 bpm.
- D. Temperature of 37°C.
Correct Answer: B
Rationale: Mild cyanosis during feeding indicates potential airway compromise, a critical concern in TEF.
When explaining the plan of care to the parents of an infant with an undescended testis, the nurse should tell the parents about which of the following as a nonsurgical treatment method?
- A. A trial of human chorionic gonadotrophic hormone.
- B. A trial of adrenocorticotropic hormone.
- C. Frequent stimulation of the cremasteric reflex.
- D. Use of several warm baths each day.
Correct Answer: A
Rationale: hCG can stimulate testicular descent in some cases.
The nurse prepares to teach an adolescent scheduled for an appendectomy about what to expect. The adolescent says, "I would rather look this up on the Internet." The nurse should:
- A. Explain that completing a teaching checklist is required by the hospital.
- B. Help the client find information on the Internet.
- C. Provide the client with written information instead.
- D. Explain that information found on the Internet cannot be trusted.
Correct Answer: B
Rationale: Assisting with finding reliable online information respects the adolescent's autonomy.