Nokea
After a tonsillectomy and adenoidectomy, which of the following findings should alert the nurse to suspect early hemorrhage in a 5-year-old child?
- A. Drooling of bright red secretions.
- B. Pulse rate of 95 bpm.
- C. Vomiting of 25 mL of dark brown emesis.
- D. Blood pressure of 95/56 mm Hg.
Correct Answer: A
Rationale: Drooling of bright red secretions indicates active bleeding, a sign of early hemorrhage post-tonsillectomy. A pulse rate of 95 bpm is within normal range for a 5-year-old, and vomiting dark brown emesis suggests older blood, not active bleeding. Blood pressure of 95/56 mm Hg is low but not specific to hemorrhage without other signs.
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A 9-year-old is given morphine for postoperative pain. As the nurse is assessing the client for pain 4 hours later, his mother leaves the room and the child begins to cry. The nurse's initial assessment of the child's pain is that he is:
- A. Not in pain because the crying began after the mother leaves.
- B. Less tolerant of pain because he is upset.
- C. In pain because he is crying.
- D. Not in pain because he was medicated 4 hours ago.
Correct Answer: B
Rationale: Emotional distress, such as the mother leaving, can lower pain tolerance, making the child more sensitive to existing pain.
To meet the developmental needs of an 8-year-old child who is confined to home with osteomyelitis, what should the nurse include in the care plan?
- A. Encouraging the child to communicate with schoolmates.
- B. Encouraging the parents to stay with the child.
- C. Allowing siblings to visit freely throughout the day.
- D. Talking to the child about his interests twice daily.
Correct Answer: A
Rationale: Encouraging communication with schoolmates supports social development and reduces isolation during home confinement.
An adolescent sustains a T3 spinal cord injury. After insertion of an intravenous line, a nasogastric tube, and an indwelling urinary (Foley) catheter, the adolescent is admitted to the intensive care unit. What should the nurse do next when assessment reveals that the adolescent's feet and legs are cool to the touch?
- A. Cover the adolescent's legs with blankets.
- B. Report this finding to the physician immediately.
- C. Reposition the adolescent's legs.
- D. Lay the adolescent flat to aid circulation.
Correct Answer: A
Rationale: Cool extremities indicate poor circulation, common in spinal cord injury; covering with blankets promotes warmth and comfort.
A mother asks, "How should I bathe my baby now that he's had surgery for his inguinal hernia?" Which of the following instructions should the nurse give the mother?
- A. Clean his face and diaper area for 2 weeks.
- B. Use sterile sponges to cleanse the inguinal incision.
- C. Give him a sponge bath daily for 1 week.
- D. Give the infant full tub baths every day.
Correct Answer: C
Rationale: Sponge baths for 1 week keep the incision dry and reduce infection risk.
The nurse is teaching a group of parents about sickle cell anemia. Which statement by a parent indicates a need for further teaching?
- A. Sickle cell anemia is a genetic disorder.'
- B. Crises can be triggered by dehydration.'
- C. The disease only affects African Americans.'
- D. Oxygen therapy may be needed during a crisis.'
Correct Answer: C
Rationale: Sickle cell anemia affects various ethnic groups, not only African Americans. The other statements are accurate, indicating understanding.