Nokea
A school-age client admitted to the hospital because of decreased urine output and periorbital edema is diagnosed with acute poststreptococcal glomerulonephritis. Which of the following actions should receive the highest priority?
- A. Assessing vital signs every 4 hours.
- B. Monitoring intake and output every 12 hours.
- C. Obtaining daily weight measurements.
- D. Obtaining serum electrolyte levels daily.
Correct Answer: C
Rationale: Weight reflects fluid status.
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When assessing a female adolescent for scoliosis, what should the nurse ask the client to do?
- A. Bend forward at the waist with arms hanging freely.
- B. Lie flat on the floor and extend her legs straight from the trunk.
- C. Sit in a chair while lifting her feet and legs to a right angle with the trunk.
- D. Stand against a wall while pressing the length of her back against the wall.
Correct Answer: A
Rationale: Bending forward at the waist with arms hanging freely allows the nurse to observe for spinal asymmetry, a key sign of scoliosis.
Which of the following outcome criteria would the nurse develop for a child with cystic fibrosis who has a nursing diagnosis of Ineffective airway clearance related to increased pulmonary secretions and inability to expectorate?
- A. Respiratory rate and rhythm within expected range.
- B. Absence of chills and fever.
- C. Ability to engage in age-related activities.
- D. Ability to tolerate usual diet without vomiting.
Correct Answer: A
Rationale: A respiratory rate and rhythm within the expected range is an appropriate outcome for ineffective airway clearance, indicating improved mucus clearance and respiratory function.
Which of the following measures would be most effective in helping the infant with a cleft lip and palate to retain oral feedings?
- A. Burp the infant at frequent intervals.
- B. Feed the infant small amounts at one time.
- C. Place the end of the nipple far to the back of the infant's tongue.
- D. Maintain the infant in a lying position while feeding.
Correct Answer: B
Rationale: Feeding small amounts at a time reduces the risk of aspiration and helps the infant manage feedings despite the cleft, promoting retention.
A nurse is reviewing a hospital's protocol for managing pediatric ingestions. Which step should be prioritized in the protocol?
- A. Administer an antidote immediately.
- B. Obtain a detailed history of the ingestion.
- C. Perform a physical examination.
- D. Order laboratory tests.
Correct Answer: B
Rationale: A detailed history (substance, amount, time) guides management decisions. Antidotes, exams, or labs follow based on history findings.
During physical assessment of a 4-month-old infant with Hirschsprung's disease, the nurse should most likely note which of the following?
- A. Scaphoid-shaped abdomen.
- B. Weight less than expected for height and age.
- C. Cyanosis of the fingers and toes.
- D. Hyperactive deep tendon reflexes.
Correct Answer: B
Rationale: Hirschsprung's disease can lead to poor weight gain due to bowel obstruction.