Nokea
An adolescent complains of chest pain and goes to the school nurse. The nurse determines that the teenager has a history of asthma but has had no problems for years. Which of the following should the nurse do next?
- A. Call the adolescent's parent.
- B. Have the adolescent lie down for 30 minutes.
- C. Obtain a peak flow reading.
- D. Give two puffs of a short-acting bronchodilator.
Correct Answer: C
Rationale: Obtaining a peak flow reading is the next step to objectively assess the adolescent's respiratory status, given the history of asthma and new chest pain, which could indicate an asthma exacerbation.
You may also like to solve these questions
A nurse is teaching the parents of a preschooler about the possibility of post-operative hemorrhage after a tonsillectomy and adenoidectomy. The nurse should explain that the risk is greatest at which of the following times?
- A. 1 to 3 days after surgery.
- B. 4 to 6 days after surgery.
- C. 7 to 10 days after surgery.
- D. 11 to 14 days after surgery.
Correct Answer: C
Rationale: The risk of post-operative hemorrhage after a tonsillectomy is greatest 7 to 10 days after surgery, as this is when the eschar (scab) typically sloughs off, potentially exposing blood vessels and leading to bleeding.
Which of the following outcome criteria would the nurse develop for a child with cystic fibrosis who has a nursing diagnosis of Ineffective airway clearance related to increased pulmonary secretions and inability to expectorate?
- A. Respiratory rate and rhythm within expected range.
- B. Absence of chills and fever.
- C. Ability to engage in age-related activities.
- D. Ability to tolerate usual diet without vomiting.
Correct Answer: A
Rationale: A respiratory rate and rhythm within the expected range is an appropriate outcome for ineffective airway clearance, indicating improved mucus clearance and respiratory function.
The nurse observes as a child with Duchenne's muscular dystrophy attempts to use from a sitting position on the floor. After attaining a kneeling position, the child 'walks' his hands up his legs to stand. The nurse documents this as which of the following?
- A. Galeazzi's sign.
- B. Goodell's sign.
- C. Goodenough's sign.
- D. Gower's sign.
Correct Answer: D
Rationale: Gower's sign is characteristic of Duchenne's muscular dystrophy, indicating proximal muscle weakness as the child uses their hands to 'walk' up their legs to stand.
After a child undergoes nephrectomy for a Wilms' tumor, the nurse should assess the child postoperatively for which early sign of a complication?
- A. Increased abdominal distention.
- B. Elevated blood pressure.
- C. Increased respiratory rate.
- D. Increased urine output.
Correct Answer: A
Rationale: Distention suggests internal bleeding.
When developing the preoperative teaching plan for a 14-month-old child with an undescended testis who is scheduled to have surgery, which of the following methods is appropriate?
- A. Telling the child that his penis and scrotum will be "fixed."
- B. Explaining to the parents how the defect will be corrected.
- C. Telling the child that he will not see any incisions after surgery.
- D. Using an anatomically correct doll to show the child what will be "fixed."
Correct Answer: B
Rationale: Parents need clear information about the procedure.