Nokea
A toddler diagnosed with nephrotic syndrome has a nursing diagnosis of Excess fluid volume related to fluid accumulation in the tissues. Which measure should the nurse anticipate including in the child's plan of care?
- A. Limiting visitors to 2 to 3 hours a day.
- B. Maintaining strict bed rest.
- C. Testing urine specific gravity every shift.
- D. Weighing the child before breakfast.
Correct Answer: D
Rationale: Daily weights monitor fluid balance.
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When developing the plan of care for a child with cystic fibrosis (CF) who is scheduled to receive postural drainage, the nurse should anticipate performing postural drainage at which of the following times?
- A. After meals.
- B. Before meals.
- C. After rest periods.
- D. Before inhalation treatments.
Correct Answer: B
Rationale: Postural drainage should be performed before meals to avoid discomfort and reduce the risk of vomiting, as it involves positioning to facilitate mucus clearance.
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.
A 10-year-old has 5 lb of Buck's extension traction on his left leg. The nurse should assess the child for which of the following? Select all that apply.
- A. Dryness of the skin, by removing the foam wraps and boot.
- B. Alignment of the shoulder, hips, and knees.
- C. Frayed rope near pulleys.
- D. Correct amount of traction weight on fracture.
- E. Pressure on the coccyx.
Correct Answer: B,C,D,E
Rationale: The nurse should check alignment, rope condition, weight accuracy, and pressure points to ensure effective and safe traction.
A child with hemophilia presents with a burning sensation in the knee and reluctance to move the body part. The nurse collaborates with the care team to provide the treatment and
- A. Administer an aspirin-containing compound.
- B. Institute Rest, Ice, Compression, and Elevation (RICE).
- C. Begin physical therapy with active range of motion.
- D. Initiate skin traction.
Correct Answer: B
Rationale: RICE reduces swelling and bleeding in hemophilic joint bleeds. Aspirin worsens bleeding, active motion is harmful, and traction is inappropriate.
After reading the vaccine information sheets, the parent of a 2-month-old infant is hesitant to consent to the recommended vaccinations. The nurse should first ask the parent:
- A. Did you know that vaccinations are required by law for school entry?
- B. What personal beliefs or safety concerns do you have about vaccinations?
- C. Would you prefer that fewer vaccines are given at a time?
- D. Can you please sign this vaccine waiver form?
Correct Answer: B
Rationale: Addressing the parent's specific concerns fosters trust and encourages informed decision-making.