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After teaching the parents of an 18-month-old who was treated for a foreign body obstruction about the three cardinal signs indicated for choking, the nurse determines that the teaching has been successful when the parents state that a child is choking when he or she cannot speak, turns blue, and does which of the following?
- A. Vomits.
- B. Gasps.
- C. Gags.
- D. Collapses.
Correct Answer: D
Rationale: The three cardinal signs of choking are inability to speak, cyanosis (turning blue), and collapse. These indicate severe airway obstruction requiring immediate intervention.
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A father of a child with a urinary tract infection calls the clinic and explains, "My wife and I are concerned because our child refuses to obey us concerning the preventions you told us about. Our child refuses to take the medication unless we buy a present. We don't want to use discipline because of the illness, but we're worried about the behavior." Which response by the nurse is best?
- A. I sympathize with your difficulties
- B. but just ignore the behavior for now.
- C. I understand it's hard to discipline a child who is ill
- D. but things need to be kept as normal as possible.
- E. I understand that things are difficult for you right now
- F. but your child is ill and deserves special treatment.
- G. I understand your concern
Correct Answer: B
Rationale: Maintaining routines is essential.
The nurse is monitoring an infant receiving IV fluids for gastroenteritis. Which finding suggests the infant is responding well to treatment?
- A. Dry mucous membranes.
- B. Weight gain of 50 grams daily.
- C. Urine output of 1 mL/kg/hour.
- D. Heart rate of 180 bpm.
Correct Answer: C
Rationale: Adequate urine output indicates effective rehydration.
The nurse reads the new medications orders for a 4-year-old child with nephrotic syndrome on the chart below: Orders D/C prednisolone 40 mg PO Daily Prednisolone 30 mg PO QOD The nurse should:
- A. Discontinue the prednisolone 40 mg and give the 30 mg dose today.
- B. Check the medication record first to see when the last dose of prednisolone was given.
- C. Start the 30 mg dose tomorrow.
- D. Contact the prescriber for clarification.
Correct Answer: D
Rationale: Clarification ensures correct dosing.
When caring for an infant post-repair of an anorectal malformation, which of the following should the nurse monitor to prevent complications?
- A. Skin integrity around the surgical site.
- B. Frequency of oral feedings.
- C. Daily weight gain.
- D. Parental bonding behaviors.
Correct Answer: A
Rationale: Monitoring skin integrity prevents infection and breakdown at the surgical site.
Nonsteroidal anti-inflammatory drugs are the first choice in treating a child with juvenile idiopathic arthritis. Which adverse effects should the nurse include in the teaching plan for the parents? Select all that apply.
- A. Weight gain.
- B. Abdominal pain.
- C. Blood in the stool.
- D. Folic acid deficiency.
- E. Reduced blood clotting ability.
Correct Answer: B,C,E
Rationale: NSAIDs can cause gastrointestinal issues like abdominal pain and blood in the stool, and they may reduce blood clotting ability due to their effect on platelet function.