Nokea
An infant with tetralogy of Fallot becomes acutely cyanotic and hyperpneic. Which action should the nurse implement first?
- A. Administer morphine sulfate.
- B. Start IV fluids.
- C. Place the infant in a knee-chest position.
- D. Provide 100% oxygen by face mask.
Correct Answer: C
Rationale: In a situation where an infant with tetralogy of Fallot is acutely cyanotic and hyperpneic, the priority action should be to place the infant in a knee-chest position. This position helps increase systemic vascular resistance, improving pulmonary blood flow and subsequently ameliorating the cyanosis and hyperpnea. It is a non-invasive and effective intervention that can be promptly implemented by the nurse to address the immediate respiratory distress.
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A 6-year-old boy with bronchial asthma takes the beta-adrenergic agonist agent albuterol (Proventil). The child's mother tells the nurse that she uses this medication to open her son's airway when he is having trouble breathing. What is the nurse's best response?
- A. Recommend that the mother bring the child in for immediate evaluation
- B. Advise the mother that overuse of the drug may cause chronic bronchitis
- C. Assure the mother that she is using the medication correctly
- D. Confirm that the medication helps to reduce airway inflammation
Correct Answer: C
Rationale: The correct response is to assure the mother that she is using the medication correctly. Albuterol is a beta-adrenergic agonist that helps open the airways during an asthma attack. By reassuring the mother, the nurse reinforces the correct usage of the medication, which is crucial in managing the child's asthma symptoms effectively.
An adolescent female who comes to the school clinic is reluctant to confide her concerns to the practical nurse (PN). The PN tells the teen that confidentiality and privacy are maintained unless a life-threatening situation arises. Which principle supports the PN's response?
- A. The adolescent should be encouraged to seek help outside of the school clinic.
- B. Disclosures from the adolescent should be kept confidential.
- C. Honest information ensures establishing a trusting relationship.
- D. Minor adolescents should not be encouraged to disclose private concerns.
Correct Answer: C
Rationale: The correct principle supporting the practical nurse's response is that honest information ensures establishing a trusting relationship. By assuring confidentiality and privacy to the adolescent unless there is a life-threatening situation, the practical nurse fosters an environment where the teen feels safe to share their concerns openly. This approach helps build trust, encouraging effective communication and support for the adolescent's well-being.
A 2-year-old is admitted to the hospital with possible encephalitis, and a lumbar puncture is scheduled. Which information should the nurse provide this child concerning the procedure?
- A. Describe the side-lying, knees to chest position that must be assumed during the procedure.
- B. Tell the child to expect loud clicking noises during the procedure that may be slightly annoying.
- C. Reassure the child that there will be no restrictions on activity after the procedure is completed.
- D. Explain that fluids cannot be taken for 8 hours before the procedure and for 4 hours after the procedure.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A 7-year-old child with cystic fibrosis is admitted to the hospital with a respiratory infection. The nurse is teaching the child's parents about the importance of chest physiotherapy (CPT). Which statement by the parents indicates they need further teaching?
- A. We should perform CPT before meals.
- B. CPT will help loosen mucus in the lungs.
- C. We should perform CPT right after the child eats.
- D. CPT is an important part of our child's treatment.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
What instructions should the nurse provide to the parents about the treatment of head lice in a 3-year-old boy who has been confirmed to have head lice?
- A. Wash the child's bed linens and clothing in hot soapy water.
- B. Dispose of the child's brushes, combs, and other hair accessories.
- C. Rewash the child's hair following a 24-hour isolation period.
- D. Take the child to a hair salon for a shampoo and shorter haircut.
Correct Answer: A
Rationale: The correct instruction for the nurse to provide to the parents is to wash the child's bed linens and clothing in hot soapy water. This is essential to eliminate head lice as they can survive on bedding and clothing. It is also important to wash any other items that the child may have used or come into contact with, such as brushes and combs, to prevent reinfestation. Rewashing the child's hair following an isolation period is not necessary, and taking the child to a hair salon for a shampoo and shorter haircut is not a recommended treatment for head lice.