Nokea
A student with type 1 diabetes tells the nurse she is feeling light-headed. The student's blood sugar is 60 mg/dL. Using the 15-15 rule, the nurse should:
- A. Give 15 mL of juice and give another 15mL in 15 minutes.
- B. Give 15 g of carbohydrate and retest the blood sugar in 15 minutes.
- C. Give 15 g of carbohydrate and 15 g of protein.
- D. Give 15 oz of juice and retest in 15 minutes.
Correct Answer: B
Rationale: The 15-15 rule involves giving 15 g of fast-acting carbohydrate (e.g., 4 oz juice) and retesting after 15 minutes to correct hypoglycemia. Protein is not immediate, and incorrect volumes (15 mL or 15 oz) are ineffective.
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A preschooler with pneumococcal meningitis is receiving intravenous antibiotic therapy. When discontinuing the intravenous therapy, the nurse allows the child to apply a dressing to the area where the needle is removed. The nurse's rationale for doing so is based on the interpretation that a child in this age-group has a need to accomplish which of the following?
- A. Trust those caring for her.
- B. Find diversional activities.
- C. Protect the image of an intact body.
- D. Relieve the anxiety of separation from home.
Correct Answer: C
Rationale: Allowing the child to apply a dressing supports their developmental need to maintain body integrity, reducing anxiety about medical procedures.
The nurse is assessing a child with leukemia who is receiving chemotherapy. Which finding indicates a potential complication requiring immediate action?
- A. A temperature of 100.4°F (38°C).
- B. A heart rate of 90 beats per minute.
- C. A platelet count of 150,000/mm³.
- D. A white blood cell count of 5,000/mm³.
Correct Answer: A
Rationale: A fever of 100.4°F in a child on chemotherapy suggests possible infection, a life-threatening complication due to immunosuppression, requiring immediate action.
Twelve hours after cardiac surgery, the nurse is assessing a 3-year-old who weighs 15 kg. The nurse should notify the surgeon about which of the following clinical finding?
- A. A urine output of 60 mL in 4 hours.
Correct Answer: A
Rationale: urine output of 60 mL in 4 hours is adequate (1 mL/kg/hr for a 15-kg child is 15 mL/hr, or 60 mL in 4 hours). No other findings are provided, so no notification is needed.
A 12-year-old client with asthma is receiving I.V. hydrocortisone, ampicillin, and theophylline. The client vomits after breakfast and lunch, is very irritable, and has a heart rate of 120 beats/minute. The nurse should:
- A. Offer small amounts of clear liquids.
- B. Inform the primary health care provider that the child is having an allergic reaction to the ampicillin.
- C. Add the missed dose of theophylline and inform the primary health care provider of the vomiting.
- D. Administer oxygen to decrease the heart rate.
Correct Answer: C
Rationale: Vomiting, irritability, and tachycardia (heart rate of 120 bpm) are signs of theophylline toxicity. The nurse should withhold further doses, inform the provider of the vomiting, and monitor for toxicity, as additional theophylline could worsen symptoms.
The nurse is assisting another member of the health care team who is placing a peripherally inserted catheter in a 10-year-old with peritonitis from a ruptured appendix. The family is present in the treatment room to support the child. The nurse observes the other team member has contaminated a sterile glove. The nurse should:
- A. Discuss the incident with the team member after the event.
- B. Report the incident to the nursing unit manager.
- C. Tell the team member the glove is contaminated.
- D. Ask the family to leave before confronting the team member.
Correct Answer: C
Rationale: Immediately addressing the contamination maintains sterility and patient safety.