Nokea
For a 14-month-old whose cleft palate was repaired 12 hours ago, which should be included in the plan of care?
- A. Allow familiar comfort items (e.g., favorite stuffed animal) and a 'sippy' cup (avoid suction items).
- B. Once liquids are tolerated, encourage a bland diet (e.g., soup, Jell-O, saltine crackers).
- C. Administer scheduled pain medication rather than PRN only.
- D. Use a Yankauer suction catheter to decrease aspiration risk.
Correct Answer: A
Rationale: Providing comfort items and avoiding suction items helps reduce distress and supports healing.
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Alveolar type of rhabdomyosarcoma accounts for approximately 1/3 of all cases of pediatric RMS and carries the poorest prognosis. Of the following, the MOST common site of involvement by alveolar type RMS is
- A. orbit
- B. middle ear
- C. extremities
- D. bladder
Correct Answer: C
Rationale: Extremities are the most common site for alveolar rhabdomyosarcoma.
A 4-month old infant who has a congenital heart defect develops heart failure and is exhibiting marked dyspnea at rest . The nurse is aware this finding can be attributed to:
- A. Anemia
- B. Hypovolemia
- C. Pulmonary edema
- D. Metabolic acidosis blood specimen is obtained. The child's color becomes blue and respiratory rate increases to 44 bpm. Which of the following actions would the nurse do first?
Correct Answer: C
Rationale: The nurse would first assess for an irregular heart rate and rhythm. In a 4-month old infant with a congenital heart defect experiencing marked dyspnea at rest, the sudden onset of cyanosis (blue coloration) and increased respiratory rate can indicate worsening heart failure and potential arrhythmias. Assessing for any abnormal heart rhythms is a priority to determine if immediate intervention is required to stabilize the infant's condition and prevent further deterioration.
Tiffany is diagnosed with increased intracranial pressure (ICP); which of the following if stated by her parents would indicate a need for Nurse Charlie to reexplain the purpose for elevating the head of the bed at a 10 to 20-degree angle?
- A. Help alleviate headache
- B. Increase intrathoracic pressure
- C. Maintain neutral position
- D. Reduce intra-abdominal pressure.
Correct Answer: B
Rationale: Elevating the head of the bed at a 10 to 20-degree angle helps to increase intrathoracic pressure. This increase in pressure can aid in promoting cerebrospinal fluid drainage and reducing intracranial pressure. It is important to maintain the correct angle to achieve the desired effect and avoid potential complications. If Tiffany's parents mention this as the reason for elevating the bed, Nurse Charlie should reexplain the purpose to ensure they understand the intended outcome.
On a visit to the gynecologist, a client complains of urinary frequency, pelvic discomfort, and weight loss. After a complete physical examination, blood studies, and a pelvic examination with a Papanicolaou test, the physician diagnoses stage IV ovarian cancer. The nurse expects to prepare the client for which initial treatment?
- A. Radiation therapy
- B. Chemotherapy
- C. Major surgery
- D. None
Correct Answer: C
Rationale: In the case of stage IV ovarian cancer, initial treatment typically involves major surgery, known as cytoreductive surgery or debulking surgery. The goal of this surgery is to remove as much of the tumor burden as possible from the abdomen and pelvis. By reducing the size of the tumor, the effectiveness of subsequent treatments such as chemotherapy can be enhanced. Surgery may also involve the removal of the uterus, ovaries, fallopian tubes, and surrounding tissue. Radiation therapy or chemotherapy may be used after surgery to further target any remaining cancer cells. However, major surgery is often the first step in the management of advanced ovarian cancer.
The nurse is caring for a patient on warfarin with an elevated INR level. Which of the ff. would be ordered as the antidote for warfarin?
- A. Vitamin K c.Calcium Chloride
- B. Vitamin B12
- C. Protamine Sulfate
Correct Answer: A
Rationale: Warfarin is an anticoagulant medication that works by inhibiting the production of certain clotting factors in the liver, thus prolonging the time it takes for blood to clot. An elevated INR level indicates that the blood is taking longer to clot than desired, potentially putting the patient at risk for bleeding. Vitamin K is the antidote for warfarin because it helps the liver produce these clotting factors, ultimately reversing the effects of warfarin and promoting normal blood clotting. Administering Vitamin K helps lower the INR level and reduce the risk of bleeding in patients on warfarin therapy. Therefore, in this scenario, Vitamin K would be the appropriate antidote to use for the patient with an elevated INR level.