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A nurse is assessing a school-age child who is receiving morphine.
For which of the following adverse effects should the nurse monitor?
- A. Prolonged wound healing
- B. Nausea
- C. Stevens-Johnson syndrome
- D. Renal failure
Correct Answer: B
Rationale: The correct answer is B: Nausea. The nurse should monitor for nausea as it is a common adverse effect of many medications and can impact the patient's overall well-being. Nausea can lead to decreased appetite, dehydration, and noncompliance with medications. Prolonged wound healing (A) is a potential adverse effect but is not as common or immediate as nausea. Stevens-Johnson syndrome (C) is a severe and life-threatening skin reaction that is rare and not typically monitored by nurses. Renal failure (D) is a serious adverse effect but may not be directly related to all medications.
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A nurse is caring for a group of clients.
Which of the following findings should the nurse report to the provider?
- A. An 18-month-old toddler who has a heart rate of 68/min
- B. A school-age child who has a rectal body temperature of 37.3° C (99.1° F)
- C. An adolescent who has a BP of 132/82 mm Hg
- D. A 3-month-old infant who has a respiratory rate of 30/min
Correct Answer: A
Rationale: The correct answer is A: An 18-month-old toddler who has a heart rate of 68/min. This finding should be reported to the provider because a heart rate of 68/min in an 18-month-old toddler is below the normal range for that age group, which is typically around 100-130/min. This could indicate bradycardia, which may be a sign of an underlying health issue that requires further evaluation and intervention. Reporting this abnormal finding promptly can help the provider assess the toddler's cardiovascular health and determine appropriate management.
The other choices are within normal ranges for their respective age groups:
B: A school-age child with a rectal temperature of 37.3°C (99.1°F) is within the normal range.
C: An adolescent with a blood pressure of 132/82 mm Hg is within the normal range for that age group.
D: A 3-month-old infant with a respiratory rate of 30/min is within the normal
Exhibit 1
Diagnostic Results Cerebrospinal fluid Pressure:
22 cm H2O (less than 20 cm H2O) Color: Cloudy (clear or colorless) Blood: None (none)
Cells
RBC: 0 (0)
WBC: 36 cells/mcL (0 to 30 cells/mcL) Protein: 92 mg/dL (up to 70 mg/dL) Glucose: 36 mg/dL
(50 to 75 mg/dL)
Serum glucose: 64 mg/dL (60 to 100 mg/dL)
A nurse in an emergency department is caring for a 3-month-old infant. Which of the following actions should the nurse take?
- A. Administer ceftriaxone.
- B. Administer pneumococcal conjugate vaccine.
- C. Initiate serum glucose testing every 1 hr.
- D. Initiate neutropenic precautions.
Correct Answer: A
Rationale: The correct answer is A: Administer ceftriaxone. In infants, ceftriaxone is commonly used for treating bacterial infections due to its broad-spectrum coverage. It is important to initiate prompt treatment in infants to prevent complications. Administering a pneumococcal conjugate vaccine (choice B) is important for prevention but not an immediate action in this scenario. Initiating serum glucose testing every 1 hr (choice C) is not necessary unless there are specific indications, as it may cause unnecessary stress to the infant. Neutropenic precautions (choice D) are not relevant in this case as there is no indication of neutropenia.
A nurse is providing discharge teaching to the guardian of a preschooler who had a tonsillectomy.
Which of the following statements should the nurse include?
- A. Notify the provider if your child has dark brown blood between their teeth.
- B. Encourage your child to drink liquids through a straw.
- C. Notify the provider if your child is swallowing frequently.
- D. Encourage your child to clear their throat as needed.
Correct Answer: C
Rationale: The correct answer is C, "Notify the provider if your child is swallowing frequently." This statement is important as frequent swallowing may indicate potential issues such as aspiration or difficulty swallowing. It is crucial for the nurse to be aware of this symptom to ensure timely intervention.
Choice A is incorrect because dark brown blood between the teeth is not a typical symptom that would require immediate notification to the provider. Choice B is also incorrect as encouraging a child to drink through a straw may not be relevant to the situation at hand. Choice D is incorrect as clearing the throat as needed may not address the underlying issue of frequent swallowing.
A nurse in the emergency department is preparing to discharge a 3-year- old child Nurses' Notes
The child's guardian states the child has been unable to sleep recently and has been very irritable. Guardian expresses concern about the child's atopic dermatitis worsening and the child scratching excessively, which results in the areas bleeding. Guardian states the child has a history of allergic rhinitis.
Assessment
Child is alert and responsive.
Respiratory rate even and nonlabored at rate of 24/min. No adventitious sounds auscultated. Heart rate 108/min
Generalized small clusters of reddish, scaly patches with lichenifications and depigmentation on the child's bilateral upper and lower extremities.
Which of the following statements should the nurse plan to include in the discharge instructions for the child's guardian?
- A. You should cut and file your child's fingernails frequently.
- B. Cystic fibrosis
- C. You should apply a thick layer of pimecrolimus cream to your child's lesions.
- D. Your child will experience occasional flare-ups of this condition.
- E. Your child's condition is contagious when lesions are present.
- F. You can apply gloves to your child's hands.
- G. "You should apply emollients to your child's skin after bathing**
Correct Answer: A,B,D,F,G
Rationale: The correct answer includes multiple important statements for the discharge instructions.
A: Cutting and filing fingernails prevent scratching and potential skin damage.
B: Cystic fibrosis is relevant medical information for the child's care.
D: Informing about occasional flare-ups helps prepare the guardian.
F: Applying gloves prevents scratching and potential skin infection.
G: Emollients maintain skin hydration and prevent dryness. These instructions promote optimal care and management of the child's condition. Other choices are incorrect as they either provide irrelevant information (C), are not necessary for the child's care (E), or do not directly contribute to the child's well-being (B).
A nurse is caring for a 6-week-old infant. History and Physical
Infant was full-term at birth. Birth weight was 3.5 kg (7.7 lb). Infant is not gaining weight as expected. One week ago at outpatient visit, weight was 3.6 kg (7.9 lb).
Parent reports for past 2 days infant is breathing faster during feedings and does not finish feedings. Parent also reports decreased appetite and puffiness around the infant's eyes. Parent states that the last wet diaper was about 10 hr ago. Infant admitted for diagnostic evaluation, failure to thrive, and nutritional/fluid support.
Vital Signs Admission:
Temperature 37.7° C (99.9° F) Heart rate 174/min while sleeping Respiratory rate 72/min while sleeping
Assessment:
Admission:
Respirations: Tachypneic with moderate retractions and nasal flaring. Upon auscultation, crackles heard in all lung fields. No nasal drainage noted. Dry cough noted periodically. Skin: Pallor, scalp is diaphoretic, lower extremities are cool to touch.
Cardiac: Tachycardic, regular rhythm, no murmur is heard. Peripheral pulses are full and bounding in the upper extremities and weak bilateral pedal pulses are noted.
Fluids: Mucous membranes are slightly dry and pink. Skin turgor is slightly decreased. Capillary refill is 3 seconds. Noted periorbital edema and nonpitting edema of feet.
Anterior fontanel is soft and slightly depressed. Diaper remains dry. Abdomen: Soft, full, round, bowel sounds are present and active.
Blood pressure in right upper extremity 60/39 mm Hg Oxygen saturation 90% Laboratory Results
Admission:
Chest x-ray: mild left ventricular hypertrophy is noted. Increased pulmonary vascular markings are noted in all lobes.
Specify 2 actions the nurse should take to address that condition.
- A. Anticipate a prescription for digoxin.
- B. Elevate the head of the bed to a 45° angle.
- C. Implement contact precautions.
- D. Provide chest physiotherapy and postural drainage.
Correct Answer: A,B
Rationale: The correct answers are A and B. A nurse should anticipate a prescription for digoxin as it is commonly prescribed for heart failure to improve heart function. Elevating the head of the bed to a 45° angle helps reduce the workload on the heart and improve respiratory function. Choice C, implementing contact precautions, is unrelated to addressing the condition. Choice D, providing chest physiotherapy and postural drainage, is not typically indicated for heart failure.