Nokea
A six-year-old girl is being admitted to the hospital for repair of an umbilical hernia. Which information, collected by the admitting nurse, is particularly helpful in planning care for this child?
- A. List of achievement timeline for developmental milestones.
- B. Mother's use of alcohol, drugs, or cigarettes during pregnancy.
- C. Reactions to any previous hospitalizations.
- D. A history of rubella, rubeola, or chicken pox.
Correct Answer: C
Rationale: Previous hospitalization reactions inform emotional and developmental care planning.
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Which snack choice by a school-aged child with gastroesophageal reflux indicates to the nurse that the child understands the dietary restrictions?
- A. Chocolate milkshake
- B. Sugar cookies
- C. Tacos
- D. Pizza
Correct Answer: B
Rationale: Sugar cookies are less likely to trigger GERD symptoms compared to high-fat or acidic foods.
A 1-year-old child with respiratory syncytial virus (RSV) is admitted to the pediatric unit. The child presents with a fever, rhinorrhea, frequent coughing, and sneezing. What additional finding should alert the nurse that the child is in acute respiratory distress?
- A. Diaphragmatic respirations.
- B. A resting respiratory rate of 35 breaths/min.
- C. Bilateral bronchial breath sounds.
- D. Flaring of the nares.
Correct Answer: D
Rationale: Nasal flaring indicates increased breathing effort, a sign of acute respiratory distress in RSV.
The nurse is getting ready to give medications to an eight-month-old infant diagnosed with heart failure. The infant's vital signs are as follows: blood pressure 114/66 mm Hg, apical pulse 88 beats/minute, and respirations 30 breaths/minute. Which medication should the nurse hold and inform the health care provider?
- A. Enalapril
- B. Digoxin
- C. Furosemide
- D. Hydralazine
Correct Answer: B
Rationale: The infant's apical pulse of 88 beats/minute is below the normal range (100-160 beats/minute) for an eight-month-old, indicating a need to hold Digoxin and notify the provider.
The nurse is evaluating a child with acute glomerulonephritis who presents at the clinic with increased fatigue, facial swelling, and decreased appetite. The child's urine sample is dark yellow. What additional finding should the nurse report to the healthcare provider?
- A. Blood pressure 88/50 mmHg
- B. Weight loss
- C. Maculopapular rash over the trunk of the body
- D. Positive rapid strep test of the oropharynx
Correct Answer: D
Rationale: A positive strep test indicates a recent infection, a common cause of glomerulonephritis, requiring reporting.
A child who weighs 30 kg is experiencing a grand mal seizure. The healthcare provider prescribes diazepam 0.3 mg/kg/dose intravenous (IV) STAT. The medication is available in 5 mg/mL vials. How many mL should the nurse administer? (Enter numeric value only. If rounding is required, round to the nearest tenth).
- A. 1.8
Correct Answer: A
Rationale: The total dose is 9 mg (30 kg × 0.3 mg/kg). Dividing by the concentration (5 mg/mL) gives 1.8 mL (9 mg ÷ 5 mg/mL).