Nokea
Assuming that all have achieved normal cognitive and emotional development, which of the following children is at greatest risk for accidental poisoning?
- A. A 6-month-old
- B. A 4-year-old
- C. A 12-year-old
- D. A 13-year-old
Correct Answer: B
Rationale: A 4-year-old is at greatest risk due to their curiosity, mobility, and tendency to explore their environment, often putting objects in their mouths.
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The nurse is caring for a neonate whose mother is diabetic. The nurse will expect the neonate to be:
- A. Hypoglycemic, small for gestational age
- B. Hyperglycemic, large for gestational age
- C. Hypoglycemic, large for gestational age
- D. Hyperglycemic, small for gestational age
Correct Answer: C
Rationale: Neonates of diabetic mothers are often large for gestational age and at risk for hypoglycemia due to maternal glucose levels.
The nurse is making initial rounds on a client with a C5 fracture. The client is in a halo vest and is receiving O2 at 40% via mask to a tracheostomy. Assessment reveals a respiratory rate of 40 and O2 saturation of 88. The client is restless. Which initial nursing action is most indicated?
- A. Notifying the physician
- B. Performing tracheal suctioning
- C. Repositioning the client to the left side
- D. Rechecking the client's O2 saturation
Correct Answer: B
Rationale: Restlessness, tachypnea, and low O2 saturation suggest airway obstruction or secretions. Tracheal suctioning is the initial action to clear the airway and improve oxygenation.
The nurse is teaching a client with an orthotopic bladder replacement. The nurse should tell the client to:
- A. Place a gauze pad over the stoma
- B. Lie on her side while evacuating the pouch
- C. Bear down with each voiding
- D. Wear a well-fitting drainage bag
Correct Answer: D
Rationale: A well-fitting drainage bag is essential for managing an orthotopic bladder replacement.
The toddler is admitted with a cardiac anomaly. The nurse is aware that the infant with a ventricular septal defect will:
- A. Tire easily
- B. Grow normally
- C. Need more calories
- D. Be more susceptible to viral infections
Correct Answer: A
Rationale: A ventricular septal defect causes increased pulmonary blood flow, leading to easy tiring due to cardiac workload.
A client is hospitalized with an acute myocardial infarction. Which nursing diagnosis reflects an understanding of the cause of acute myocardial infarction?
- A. Decreased cardiac output related to damage to the myocardium
- B. Impaired tissue perfusion related to an occlusion in the coronary vessels
- C. Acute pain related to cardiac ischemia
- D. Ineffective breathing patterns related to decreased oxygen to the tissues
Correct Answer: B
Rationale: Impaired tissue perfusion due to coronary occlusion is the primary cause of acute myocardial infarction.