Nokea
An infant is to be discharged after surgery for intussusception. In developing the discharge teaching plan, the nurse should tell the mother?
- A. The infant will experience a change in the normal home routine.
- B. The infant can return to the prehospital routine immediately.
- C. The infant needs to ingest more calories at home than normal.
- D. The infant will continue to experience abdominal cramping for a few days.
Correct Answer: B
Rationale: After successful surgery, the infant can typically resume normal routines unless complications arise.
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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.
The nurse is transferring a child who has had open heart surgery from the pediatric intensive care unit to the pediatric unit. The child's blood pressure has been fluctuating but has been stable during the last 2 hours. The nurse from the pediatric intensive care unit should include which of the following information in the report to the nurse on the pediatric unit?
- A. Medications being used.
- B. Current vital signs.
- C. Potential for blood pressure to drop.
- D. Drip rate for the intravenous infusion.
- E. Time of the most recent dose of pain medication.
Correct Answer: A,B,C,D,E
Rationale: All listed information is critical for continuity of care, ensuring the receiving nurse can monitor and manage the child's condition effectively.
The physician orders an intravenous infusion of 5% dextrose in 0.25 normal saline to be infused at 2 mL/kg/hour in an infant who weighs 9 lb. How many milliliters per hour of the solution should the nurse infuse? Round to one decimal.
- A. 8.2 mL/hour
- B. 9.0 mL/hour
- C. 7.4 mL/hour
- D. 6.8 mL/hour
Correct Answer: A
Rationale: 9 lb = 4.08 kg; 2 mL/kg/hour × 4.08 kg = 8.16 mL/hour, rounded to 8.2.
The nurse is caring for a 2-year-old with iron deficiency anemia. Which laboratory finding would the nurse expect to see?
- A. Elevated hemoglobin levels.
- B. Decreased mean corpuscular volume (MCV).
- C. Increased serum ferritin levels.
- D. Elevated white blood cell count.
Correct Answer: B
Rationale: Iron deficiency anemia typically shows decreased MCV, indicating microcytic red blood cells, due to reduced iron availability for hemoglobin synthesis.
A child who was intubated after a craniotomy now shows signs of decreased level of consciousness. The physician orders manual hyperventilation to keep the PaCO2 between 25 and 29 mm Hg and the PaO2 between 80 and 100 mm Hg. The nurse interprets this order based on the understanding that this action will accomplish which of the following?
- A. Decrease intracranial pressure.
- B. Ensure a patent airway.
- C. Lower the arousal level.
- D. Produce hypoxia.
Correct Answer: A
Rationale: Hyperventilation lowers PaCO2, causing vasoconstriction and reducing intracranial pressure in brain tumor patients.