Nokea
After surgery to repair a tracheoesophageal fistula, an infant receives gastrostomy tube feedings. After feeding the infant by this method, the nurse positions the infant with the head elevated for approximately 30 minutes, primarily to help accomplish which of the following?
- A. Promote intestinal peristalsis.
- B. Prevent regurgitation of formula.
- C. Relieve pressure on the surgical site.
- D. Associate eating with a pleasurable experience.
Correct Answer: B
Rationale: Head elevation reduces the risk of formula reflux, protecting the surgical site and airway.
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What should be part of the nurse's teaching plan for a child with epilepsy being discharged on a regimen of diphenylhydantoin (Dilantin)?
- A. Drinking plenty of fluids.
- B. Brushing teeth after each meal.
- C. Having someone be with the child during waking hours.
- D. Reporting signs of infection.
Correct Answer: B
Rationale: Dilantin can cause gingival hyperplasia; brushing after meals promotes oral hygiene to mitigate this side effect.
The nurse assesses the family's ability to cope with the child's cerebral palsy. Which action should alert the nurse to the possibility of their inability to cope with the disease?
- A. Limiting interaction with extended family and friends.
- B. Learning measures to meet the child's physical needs.
- C. Requesting teaching about cerebral palsy in general.
- D. Not seeking financial help to pay for medical bills.
Correct Answer: A
Rationale: Limiting social interactions may indicate social isolation, a sign of poor coping, whereas the other options suggest proactive engagement with the child's needs.
After emphasizing to an adolescent with renal failure the importance of maintaining a positive self-concept, which of the following behaviors by the adolescent should the nurse identify as an indicator that the plan is working?
- A. Reports of headaches, abdominal pain, and nausea.
- B. Insistence on making diet choices even if the foods chosen are restricted.
- C. Verbalization of plans to quit all after-school activities when returning home.
- D. Demonstration of desire to do the dressing changes and take care of the medications.
Correct Answer: D
Rationale: Self-care indicates positive adjustment.
The nurse is conducting a quality improvement audit on the pediatric unit. Which finding indicates a need for further staff education on IV catheter care?
- A. IV sites checked every 2 hours.
- B. Use of transparent dressings.
- C. Infiltration rates above 10%.
- D. Documentation of insertion dates.
Correct Answer: C
Rationale: High infiltration rates suggest improper technique or monitoring, requiring education.
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.