Nokea
A toddler is brought to the emergency room after ingesting an undetermined amount of drain cleaner. The nurse should expect to assist with which of the following first?
- A. Administering an emetic.
- B. Performing a tracheostomy.
- C. Performing gastric lavage.
- D. Inserting an indwelling urinary (Foley) catheter.
Correct Answer: C
Rationale: Gastric lavage is the priority to remove the corrosive substance from the stomach, preventing further damage. Emetics are contraindicated for corrosives as they can worsen injury. Tracheostomy may be needed later for airway issues, and a urinary catheter is not relevant initially.
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When teaching the parents of a child with a ventricular septal defect who is scheduled for a cardiac catheterization, the nurse explains that this procedure involves the use of which of the following?
- A. Ultra-high-frequency sound waves.
- B. Catheter placed in the right femoral vein.
- C. Cutdown procedure to place a catheter.
- D. General anesthesia.
Correct Answer: B
Rationale: Cardiac catheterization involves inserting a catheter, typically through the femoral vein, to assess heart structures. Ultra-high-frequency sound waves are used in echocardiography, a cutdown is not standard, and general anesthesia is not always required.
A child with nephrosis is placed on prednisone. The dose is 2 mg/kg/day to be administered twice a day. The child weighs 25 lb. How many milligrams will the child receive at each dose?
Correct Answer: 22.7
Rationale: Convert weight to kg, then calculate dosage.
When developing the teaching plan for the mother and a child with insulin-dependent diabetes about sick-day management, which of the following instructions should the nurse include?
- A. Adhere to the same schedule and type and amount of insulin.
- B. Immediately call the physician for information about what to do.
- C. Adjust insulin based on more frequent testing of blood glucose levels.
- D. Take the child to the emergency department for immediate care.
Correct Answer: C
Rationale: Sick-day management requires frequent glucose monitoring and insulin adjustments to prevent ketoacidosis. Fixed insulin schedules, immediate physician calls, or ER visits are less appropriate without monitoring.
Which assessment findings should lead the nurse to suspect that a toddler is experiencing respiratory distress? Select all that apply.
- A. Coughing.
- B. Respiratory rate of 35 breaths/minute.
- C. Heart rate of 95 beats/minute.
- D. Restlessness.
- E. Malaise.
- F. Diaphoresis.
Correct Answer: B,D,F
Rationale: A respiratory rate of 35 breaths/minute (elevated for a toddler), restlessness, and diaphoresis indicate respiratory distress, reflecting increased work of breathing and stress. Coughing may be present but is less specific, while a heart rate of 95 bpm and malaise are not directly indicative of acute respiratory distress.
The nurse is caring for a child who has just returned from surgery for repair of a cleft lip. In which order, from first to last, should the nurse do the following?
- A. Maintain a clear and adequate airway.
- B. Maintain sufficient fluid and caloric intake.
- C. Provide emotional comfort to the child.
- D. Apply elbow restraints.
- E. Teach the parents proper feeding methods.
Correct Answer: A,B,C,D,E
Rationale: Postoperative care prioritizes airway maintenance to ensure breathing, followed by fluid and caloric intake for recovery, emotional comfort to reduce stress, elbow restraints to protect the surgical site, and finally teaching parents feeding methods for ongoing care.