Nokea
An infant has been transferred from the ICU to the pediatric floor after undergoing surgery to correct a heart defect. Which tasks can the nurse delegate to the licensed practical nurse (LPN)?
- A. Administering oral medications.
- B. Administering I.V. morphine.
- C. Obtaining vital signs.
- D. Recording the input and output.
- E. Administering blood products.
- F. Morning hygiene.
- G. Circulation checks.
Correct Answer: A,C,D,F,G
Rationale: LPNs can handle oral medications, vital signs, input/output, hygiene, and circulation checks. I.V. morphine and blood products require RN oversight.
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After teaching a child with leukemia scheduled for a bone marrow aspiration about the procedure, the nurse determines that the teaching has been successful when the child identifies which of the following as the site for the aspiration?
- A. Right lateral side of the right wrist.
- B. Middle of the chest.
- C. Distal end of the thigh.
- D. Back of the hipbone.
Correct Answer: D
Rationale: Bone marrow aspiration is typically performed at the iliac crest (hipbone). Other sites are incorrect.
During a developmental screening, the nurse finds that a 3-year-old child with cerebral palsy has arrested social and language development. The nurse tells the family:
- A. This is a sign the cerebral palsy is progressing.'
- B. Your child has reached his maximum language abilities.'
- C. I need to refer you for more developmental testing.'
- D. We need to modify your therapy plan.'
Correct Answer: C
Rationale: Arrested development requires further evaluation to determine the cause and appropriate interventions, so referral for additional testing is necessary.
When performing cardiopulmonary resuscitation (CPR), which of the following indicates that external chest compressions are effective?
- A. Mottling of the skin.
- B. Pupillary dilation.
- C. Palpable pulse.
- D. Cool, dry skin.
Correct Answer: C
Rationale: A palpable pulse during CPR indicates effective chest compressions, as it confirms adequate circulation.
Which statement by the mother of a child with Wilms' tumor tells the nurse that the mother understands what stage II tumor means?
- A. The tumor has extended beyond the kidney but was completely removed.
- B. Although the tumor was in the kidney, it has spread to the lung, liver, and bone.
- C. The tumor has extended outside the kidney to the lungs and the liver.
- D. The tumor was solely located in the kidney but it was totally removed.
Correct Answer: A
Rationale: Stage II indicates removal beyond kidney.
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.