Nokea
A toddler who has been hospitalized for vomiting due to gastroenteritis is sleeping and difficult to wake up. Assessment reveals: HR: 220 beats per minute (regular) Respiratory rate: 30 per minute BP: 84/52 Capillary refill: 3 seconds Which dysrhythmia does the nurse suspect in this child?
- A. Rapid pulmonary flutter
- B. Sinus bradycardia
- C. Rapid atrial fibrillation
- D. Supraventricular tachycardia (SVT)
Correct Answer: D
Rationale: SVT is typically above 200 beats per minute and can result from dehydration; the rapid rate causes low cardiac output (CO), resulting in low BP and prolonged capillary refill.
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The nurse is caring for a child with acute glomerulonephritis. Which of the following would most likely indicate that the child’s condition is improving?
- A. Increased urine output with normal color and consistency
- B. Decrease in the blood pressure
- C. A reduction in protein levels in the urine
- D. A decrease in hematuria
Correct Answer: A
Rationale: Improved renal function is indicated by increased urine output and the return of urine to normal color and consistency.
A child has a Glasgow Coma Scale of 3, HR of 88 beats per minute and regular, respiratory rate of 22, BP of 78/52, and blood sugar of 35 mg/dL. The nurse asks the caregiver about accidental ingestion of which drug?
- A. Calcium channel blocker
- B. Beta blocker
- C. ACE inhibitor
- D. ARB
Correct Answer: B
Rationale: Beta blockers affect the heart and also block beta receptors in the liver, reducing glycogen release and causing hypoglycemia. The low HR and BP support beta blocker ingestion.
Following surgical repair of the bladder, a female client is being discharged from the hospital to home with an indwelling urinary catheter. Which instruction is most important for the nurse to provide to this client?
- A. Avoid coiling the tubing and keep if free of kinks
- B. Cleanse the perineal area with soap and water twice daily
- C. Keep the drainage bag lower than the level of the bladder
- D. Drink 1,000 ml of fluids daily to irrigate catheter
Correct Answer: C
Rationale: Keeping the drainage bag lower than the bladder prevents backflow of urine, reducing the risk of infection.
Elevated levels of CPK are seen in:
- A. Duchenne muscular dystrophy
- B. Dermatomyositis
- C. Spinal muscular atrophy
- D. Malignant hyperthermia
Correct Answer: A
Rationale: Duchenne muscular dystrophy: Elevated creatine phosphokinase (CPK) levels are a hallmark of Duchenne muscular dystrophy due to muscle damage and degeneration.
Which statement by the mother of a child with rheumatic fever (RF) shows she has a good understanding of the care of her child?
- A. I will apply heat to his swollen joints to promote circulation.
- B. I will have him do gentle stretching exercises to prevent contractures.
- C. I will give him the aspirin that is ordered for pain and inflammation.
- D. I will apply cold packs to his swollen joints to reduce pain.
Correct Answer: C
Rationale: Aspirin is the drug of choice for treating RF due to its anti-inflammatory and analgesic properties.