Nokea
Before administering a tube feeding to a child, what should the practical nurse (PN) assess?
- A. Tube placement.
- B. Bowel sounds.
- C. Abdominal circumference.
- D. Tube patency.
Correct Answer: A
Rationale: Assessing tube placement is critical before initiating a tube feeding to verify its correct positioning in the stomach. This assessment helps prevent potential complications such as aspiration if the tube is incorrectly placed in the respiratory tract. Checking bowel sounds, abdominal circumference, and tube patency are important assessments in the care of a child receiving tube feedings, but ensuring proper tube placement takes precedence to ensure safe and effective delivery of nutrition.
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A 10-year-old child is being discharged after being admitted for status asthmaticus. Which instruction is most important for the nurse to include in the discharge teaching?
- A. Use a peak flow meter daily to monitor asthma control
- B. Avoid exposure to known allergens
- C. Continue taking asthma medications as prescribed
- D. Seek emergency care if symptoms worsen
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A 2-year-old child with heart failure (HF) is admitted for replacement of a graft for coarctation of the aorta. Prior to administering the next dose of digoxin (Lanoxin), the nurse obtains an apical heart rate of 128 bpm. What action should the nurse take?
- A. Determine the pulse deficit.
- B. Administer the scheduled dose.
- C. Calculate the safe dose range.
- D. Review the serum digoxin level.
Correct Answer: B
Rationale: Administering the scheduled dose is appropriate in this scenario since the heart rate of 128 bpm is within an acceptable range for a 2-year-old child with heart failure. Monitoring for signs of digoxin toxicity is important; however, the immediate action required is to administer the scheduled dose as prescribed based on the heart rate assessment.
During a follow-up clinical visit, a mother tells the nurse that her 5-month-old son, who had surgical correction for tetralogy of Fallot, has rapid breathing, often takes a long time to eat, and requires frequent rest periods. The infant is not crying while being held, and his growth is in the expected range. Which intervention should the nurse implement?
- A. Stimulate the infant to cry to produce cyanosis
- B. Auscultate the heart and lungs while the infant is held
- C. Evaluate the infant for failure to thrive
- D. Obtain a 12-lead electrocardiogram
Correct Answer: B
Rationale: Auscultating the heart and lungs while the infant is held can provide important diagnostic information in assessing the cardiac and respiratory status of the infant who had surgical correction for tetralogy of Fallot. This intervention can help the nurse identify any abnormal heart or lung sounds, which may indicate complications or issues that need further evaluation or intervention.
When observing a distraught mother scolding her 3-year-old son for wetting his pants in the hallway of a pediatric unit, what initial action should the nurse take?
- A. Suggest that the mother consult a pediatric nephrologist.
- B. Provide disposable training pants while calming the mother.
- C. Refer the mother to a community parent education program.
- D. Inform the mother that toilet training is slower for boys.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
When developing a behavior modification program for an extremely aggressive 10-year-old boy, what should the nurse do first?
- A. Identify what activities, foods, and toys the child enjoys
- B. Assess the child's previous reactions to punishment
- C. Offer the child positive feedback
- D. Involve other children on the unit in describing the token system
Correct Answer: A
Rationale: The first step in developing a behavior modification program for an extremely aggressive 10-year-old boy is to identify what activities, foods, and toys the child enjoys. Understanding the child's motivations is crucial in creating an effective behavior modification plan tailored to his interests and preferences, which can help in positively reinforcing desired behaviors.