Nokea
An infant who had cardiac surgery for a congenital defect is to be discharged. What should the nurse emphasize to the parents regarding administering the prescribed antibiotic?
- A. Give the antibiotic between feedings.
- B. Ensure that the antibiotic is administered as prescribed.
- C. Shake the bottle thoroughly before administering the antibiotic.
- D. Keep the antibiotic in the refrigerator after opening the bottle.
Correct Answer: B
Rationale: The correct answer is B: 'Ensure that the antibiotic is administered as prescribed.' It's crucial to stress the importance of following the prescribed antibiotic regimen to prevent infections and promote proper healing after cardiac surgery. Choice A is incorrect because it does not address the fundamental aspect of adherence to the prescription. Choice C is incorrect as shaking the bottle may not be necessary for all antibiotics and is not a critical instruction in this context. Choice D is incorrect as storage instructions are not directly related to the administration of the antibiotic as prescribed, which is the primary concern in this scenario.
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The nurse is conducting a physical examination of a 9-month-old baby with a flat, discolored area on the skin. The nurse documents this as a:
- A. Papule
- B. Macule
- C. Vesicle
- D. Scale
Correct Answer: B
Rationale: A macule is defined as a flat, discolored area on the skin that is different from surrounding tissue due to a change in color. In this case, the baby has a flat, discolored area on the skin, which fits the description of a macule. A papule is a small, raised solid bump, a vesicle is a small fluid-filled blister, and a scale is a flake of skin that is often dry and rough. Therefore, choices A, C, and D do not accurately describe the flat, discolored area on the baby's skin, making them incorrect.
You are caring for a 6-year-old child with a possible fractured left arm and have reason to believe that the child was abused. How should you manage this situation?
- A. inform the parents of your suspicions
- B. call the police so the parents can be arrested
- C. advise the parents that the child needs to be transported
- D. transport the child to the hospital regardless of the parents' wishes
Correct Answer: C
Rationale: In cases where child abuse is suspected, the priority is the safety and well-being of the child. Advising the parents that the child needs to be transported allows for the child to receive necessary medical care without immediate confrontation or escalating the situation. Calling the police to have the parents arrested without concrete evidence may not be appropriate and could further endanger the child. Informing the parents of suspicions may lead to interference or denial of necessary care. Transporting the child to the hospital is crucial, but involving and engaging with the parents in a non-confrontational manner is the initial step to ensure the child's safety and well-being.
During a check-up for a 5-year-old child with eczema before school starts, what will the nurse do?
- A. Change the bandage on a cut on the child's hand.
- B. Assess the compliance with treatment regimens.
- C. Discuss systemic corticosteroid therapy.
- D. Assess the child's fluid volume.
Correct Answer: B
Rationale: Assessing compliance with treatment regimens is crucial in managing eczema effectively and preventing flare-ups. This involves ensuring that the child is following the prescribed treatment plan, which may include medication application, skincare routines, and lifestyle modifications. Changing a bandage on a cut would not be a routine part of an eczema check-up unless there was a specific wound related to eczema. Discussing systemic corticosteroid therapy may be part of the management plan for severe eczema cases but would not be the primary focus during a routine check-up. Assessing the child's fluid volume, while important in general health assessments, is not directly related to managing eczema specifically.
An order is written for an isotonic enema for a 2-year-old child. What is the maximum amount of fluid the nurse should administer without a specific order from the healthcare provider?
- A. 100 to 150 mL
- B. 155 to 250 mL
- C. 255 to 360 mL
- D. 365 to 500 mL
Correct Answer: B
Rationale: For a 2-year-old child, the maximum recommended amount of fluid for an isotonic enema is between 155 to 250 mL. This range is considered safe to prevent overdistension and potential harm to the child's rectum. Choices A, C, and D exceed the safe range for a 2-year-old child and can lead to complications such as bowel perforation or electrolyte imbalances.
During a physical examination of a 9-month-old baby, the nurse observes a flat, discolored area on the skin. The nurse documents this as a:
- A. Papule.
- B. Macule.
- C. Vesicle.
- D. Scale.
Correct Answer: B
Rationale: The correct answer is B: Macule. A macule is a flat, discolored area on the skin that is smaller than 1 cm in diameter. This term is used to describe conditions like freckles or petechiae. Choice A, Papule, refers to a small, solid, raised skin lesion (<0.5 cm) like a pimple. Choice C, Vesicle, describes a small blister filled with clear fluid. Choice D, Scale, refers to flakes or plates of dead skin that may be dry or greasy.