Because the burned child is confined to bed, the nurse asses...

Because the burned child is confined to bed, the nurse assesses for footdrop. Which nursing action best prevents the development of footdrop?

A. Apply braces to the feet and ankles.
B. Keep the child in the side-lying position.
C. Keep sheets tucked in at the foot of the bed.
D. Rest the child's feet against a footboard.

Correct Answer: D

Rationale: Resting the child's feet against a footboard maintains the feet in a neutral position, preventing plantar flexion and footdrop during prolonged bed rest.

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Which statement by the nurse is most therapeutic in addressing the teen's behavior?

A. There's nothing to be scared of. This won't hurt.
B. The stitches are strong. They won't come out.
C. I know you're scared, but you must be brave.
D. Let's do this later, when you're better prepared.

Correct Answer: C

Rationale: Acknowledging the teen's fear and encouraging bravery validates their emotions while gently motivating them to proceed with ambulation, fostering trust and cooperation.

A child weighs 22 kg and is prescribed a medication at 5 mg/kg/day in two divided doses. How many milligrams should the nurse administer per dose?

Correct Answer: 55 mg

Rationale: Calculation: 22 kg × 5 mg/kg/day = 110 mg/day. Divided into two doses: 110 ÷ 2 = 55 mg per dose. Since no options are provided, the calculated dose is noted for accuracy.

During preoperative preparation, which nursing action is most appropriate?

A. Give analgesics.
B. Give nothing by mouth (NPO).
C. Give an enema.
D. Apply heat to the abdomen.

Correct Answer: B

Rationale: Keeping the patient NPO prevents aspiration during surgery and reduces complications, as food in the stomach could interfere with anesthesia.

The nurse has just assisted with the birth of a full-term infant. The nurse should take which measures immediately to promote parent-infant attachment? Select all that apply.

A. Have the mother nap before interacting with her newborn.
B. Dim the lights in the birthing room.
C. Place the newly delivered infant on the mother’s abdomen.
D. Delay instilling the ophthalmic antibiotic for an hour.
E. Play loud music to keep the infant stimulated.
F. Ask the parents to delay phone calls for an hour after birth.

Correct Answer: B,C,D,F

Rationale: Dimming lights encourages eye contact skin-to-skin contact improves interaction delaying antibiotic ointment prevents blurred vision and delaying phone calls maximizes bonding time. Napping misses the alert period and loud music is overstimulating.

Which question is most important for the nurse to ask the adolescent girl in preparation for X-rays?

A. Is there any possibility that you're pregnant?
B. Have you eaten anything in the past 24 hours?
C. Have you taken any medications in the past 24 hours?
D. Are you allergic to iodine or shellfish?

Correct Answer: A

Rationale: Asking about pregnancy is critical before X-rays, as radiation can harm a fetus, making it the most important question to ensure safety.