Nokea
A school-age child who has received burns over 60% of his body is to receive 2,000 mL of I.V. fluid over the next 8 hours. At what rate (in milliliters per hour) should the nurse set the infusion pump?
Correct Answer: 250
Rationale: Dividing 2,000 mL by 8 hours yields 250 mL/hour. This ensures fluid resuscitation meets burn protocol (e.g., Parkland formula) to maintain hemodynamic stability.
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An 8-year-old with diabetes is placed on neutral and immune Hagedorn (NPH) and regular insulin before breakfast and before dinner. She will receive a snack of milk and cereal at bedtime. The snack will:
- A. Help her regain lost weight.
- B. Provide carbohydrates for immediate use.
- C. Prevent late night hypoglycemia.
- D. Help her stay on her diet.
Correct Answer: C
Rationale: A bedtime snack with NPH insulin prevents late-night hypoglycemia by providing carbohydrates during peak insulin action. It is not primarily for weight gain, immediate use, or diet adherence.
Which of the following would be most appropriate for the nurse to teach the mother of a 6-month-old infant hospitalized with severe diarrhea to help her comfort her infant who is fussy?
- A. Offering a pacifier.
- B. Placing a mobile above the crib.
- C. Sitting at crib side talking to the infant.
- D. Turning the television on to cartoons.
Correct Answer: A
Rationale: A pacifier provides non-nutritive sucking, soothing a fussy infant.
An 18-month-old with a congenital heart defect is to receive digoxin twice a day. The nurse should instruct the parents about which of the following?
- A. Digoxin enables the heart to pump more effectively with a slower and more regular rhythm.
- B. Signs of toxicity include loss of appetite, vomiting, increased pulse, and visual disturbances.
- C. Digoxin is absorbed better if taken with meals.
- D. If the child vomits within 15 minutes of administration, the dosage should be repeated.
Correct Answer: A
Rationale: Digoxin improves heart function by increasing contractility and regulating rhythm. Toxicity signs are correct but not the focus here, absorption is not meal-dependent, and repeating a vomited dose risks overdose.
Laboratory findings indicate that a child with leukemia is also anemic. The nurse interprets this finding as most likely resulting from which of the following?
- A. Inadequate dietary folic acid intake.
- B. Decreased red blood cell production.
- C. Increased destruction of red blood cells by lymphocytes.
- D. Progressive replacement of bone marrow with scar tissue.
Correct Answer: B
Rationale: Leukemia crowds out bone marrow, reducing red blood cell production, causing anemia. Other causes are less likely.
A nurse working in the nursery identifies a goal for a mother of a newborn to demonstrate positive attachment behaviors upon discharge. Which intervention would be least effective in accomplishing this goal?
- A. Provide opportunities for the mother to hold and examine the newborn.
- B. Engage the mother in the newborn's care.
- C. Create an environment that fosters privacy for the mother and newborn.
- D. Identify strategies to prevent difficulties in parenting.
Correct Answer: D
Rationale: Preventing parenting difficulties is less directly related to fostering immediate attachment.