Nokea
A transfusion of packed red blood cells has been ordered for a 1-year-old with sickle cell anemia. The infant has a 25 gauge I.V. infusing dextrose with sodium and potassium. Using the Situation, Background, Assessment, Recommendation (SBAR) method of communication, the nurse contacts the physician and recommends:
- A. Starting a second I.V. with a 22 gauge catheter to infuse normal saline with the blood.
- B. Using the existing I.V., but changing the fluids to normal saline for the transfusion.
- C. Replacing the I.V. with a 22 gauge catheter to infuse the ordered fluids.
- D. Starting a second I.V. with a 25 gauge catheter to infuse normal saline with the transfusion.
Correct Answer: A
Rationale: A second I.V. with a larger 22-gauge catheter ensures safe blood transfusion, as dextrose is incompatible and a 25-gauge is too small.
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The toddler with nephrotic syndrome exhibits generalized edema. Which of the following measures should the nurse institute for this child with a nursing diagnosis of Impaired skin integrity related to edema?
- A. Ambulate every shift while awake.
- B. Apply lotion on opposing skin surfaces.
- C. Apply powder to skinfolds.
- D. Separate opposing skin surfaces with soft cloth.
Correct Answer: D
Rationale: Prevent skin breakdown.
A hospitalized preschooler with meningitis who is to be discharged becomes angry when the discharge is delayed. Which of the following play activities would be most appropriate at this time?
- A. Reading the child a story.
- B. Painting with watercolors.
- C. Pounding on a pegboard.
- D. Stacking a tower of blocks.
Correct Answer: C
Rationale: Pounding on a pegboard allows the child to express frustration physically, which is developmentally appropriate for a preschooler.
Parents bring their child to the emergency department because the child has stopped breathing. A nurse obtains a brief history of events occurring before and after the parents found the infant not breathing. Which of the following questions should the nurse ask the parents first?
- A. Was the infant sleeping while wrapped in a blanket?
- B. Was the infant lying on his stomach?
- C. What did the infant look like when you found him?
- D. When had you last checked on the infant?
Correct Answer: B
Rationale: Asking if the infant was lying on his stomach is critical, as prone sleeping is a major risk factor for SIDS and could explain the cessation of breathing.
The stool culture of a child with profuse diarrhea reveals Salmonella bacilli. After teaching the mother about Salmonella, which of the following statements by the mother indicates effective teaching?
- A. Some people become carriers and stay infectious for a long time.
- B. After the acute stage passes, the organism is usually not present in the stool.
- C. Although the organism may be alive indefinitely, in time it will be of no danger to anyone.
- D. If my child continues to have the organism in the stool, an antitoxin can help destroy the organism.
Correct Answer: A
Rationale: Salmonella can lead to a carrier state with prolonged infectiousness.
When teaching an adolescent with a seizure disorder who is receiving valproic acid (Depakene), which sign or symptom should the nurse instruct the client to report to the health care provider?
- A. Three episodes of diarrhea.
- B. Loss of appetite.
- C. Jaundice.
- D. Sore throat.
Correct Answer: C
Rationale: Jaundice indicates potential liver toxicity, a serious side effect of valproic acid, requiring immediate reporting.