Nokea
After a child returns from surgery for a tracheostomy, what is the priority nursing action?
- A. Suctioning the tracheostomy tube
- B. Changing the tracheostomy dressing
- C. Monitoring respiratory status
- D. Ensuring the tracheostomy ties are secure
Correct Answer: A
Rationale: The priority nursing action after a tracheostomy surgery is to suction the tracheostomy tube. Suctioning helps maintain a clear airway and prevent complications such as airway obstruction or respiratory distress. While monitoring respiratory status is important, suctioning takes precedence immediately post-surgery to ensure adequate air exchange. Changing the tracheostomy dressing and ensuring tracheostomy ties are secure are also essential tasks but are secondary to the critical need for airway maintenance through suctioning.
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A 3-year-old child ingests a substance that may be a poison. The parent calls a neighbor who is a nurse and asks what to do. What should the nurse recommend the parent to do?
- A. Administer syrup of ipecac.
- B. Call the poison control center.
- C. Take the child to the emergency department.
- D. Give the child bread dipped in milk to absorb the poison.
Correct Answer: B
Rationale: In cases of potential poisoning, immediate guidance from professionals is crucial. Administering syrup of ipecac is no longer recommended routinely due to potential risks and lack of benefit. Taking the child to the emergency department is necessary in severe cases but may not always be the immediate action needed. Giving the child bread dipped in milk is not an appropriate method to manage poisoning and could potentially worsen the situation. Therefore, the most appropriate action for the nurse to recommend is to call the poison control center for expert advice on managing the situation.
When a family decides to withhold 'extraordinary care' for a newborn with severe abnormalities, what does this decision indicate?
- A. The newborn has no rights.
- B. It is the same as euthanasia.
- C. It is illegal professional practice.
- D. The newborn is being allowed to die.
Correct Answer: D
Rationale: When a family decides to withhold 'extraordinary care' for a newborn with severe abnormalities, it means that aggressive interventions will not be pursued, allowing the newborn to die naturally. This decision is legal and ethical, respecting the principle of non-maleficence by avoiding unnecessary suffering. Choice A is incorrect because all individuals, including newborns, have rights, but the decision to withhold extraordinary care is based on ethical considerations. Choice B is incorrect as withholding care is not the same as euthanasia, which involves actively ending life. Choice C is incorrect as long as the decision is made within legal and ethical boundaries, it is not considered illegal professional practice.
A healthcare provider is assessing a child with suspected rheumatic fever. What clinical manifestation is the provider likely to observe?
- A. Jaundice
- B. Peeling skin on the hands and feet
- C. High fever
- D. Severe joint pain
Correct Answer: D
Rationale: Severe joint pain is a classic symptom of rheumatic fever, resulting from inflammation of the joints. Rheumatic fever primarily affects the joints, heart, skin, and the central nervous system. Jaundice (Choice A) is not typically associated with rheumatic fever. Peeling skin on the hands and feet (Choice B) is more characteristic of conditions like Kawasaki disease. While high fever (Choice C) can be present in rheumatic fever, it is not as specific or characteristic as severe joint pain.
A child with diabetes insipidus is being treated with vasopressin. The nurse would assess the child closely for signs and symptoms of which condition?
- A. Syndrome of inappropriate antidiuretic hormone (SIADH)
- B. Thyroid storm
- C. Cushing syndrome
- D. Vitamin D toxicity
Correct Answer: A
Rationale: The correct answer is A: Syndrome of inappropriate antidiuretic hormone (SIADH). Vasopressin is a medication used to treat diabetes insipidus by increasing water reabsorption in the kidneys. However, an excessive dose of vasopressin can lead to water retention, causing SIADH, which is characterized by dilutional hyponatremia. Choices B, C, and D are incorrect. Thyroid storm is a severe form of hyperthyroidism characterized by increased metabolism and can lead to life-threatening complications. Cushing syndrome results from excess cortisol production and is characterized by weight gain, hypertension, and other features. Vitamin D toxicity occurs due to an overdose of vitamin D, leading to hypercalcemia and symptoms such as nausea, vomiting, and weakness.
A 3-month-old infant has been hospitalized with respiratory syncytial virus (RSV). What is the priority intervention?
- A. Administering an antiviral agent
- B. Clustering care to conserve energy
- C. Offering oral fluids to promote hydration
- D. Providing an antitussive agent when necessary
Correct Answer: B
Rationale: The priority intervention for a 3-month-old infant hospitalized with respiratory syncytial virus (RSV) is to cluster care to conserve energy. Infants with RSV often have difficulty breathing and need to rest frequently. Clustering care involves grouping nursing interventions to allow for longer periods of rest between activities, which helps prevent exhaustion and conserve the infant's energy. Administering an antiviral agent is not the primary intervention for RSV, as it is a viral infection and antiviral agents are not typically used for RSV. Offering oral fluids is important for hydration but may not be the priority when the infant is struggling to breathe. Providing an antitussive agent should be done judiciously and under medical guidance, as suppressing the cough reflex can be detrimental in RSV cases where coughing helps clear airway secretions.