Nokea
If the child develops shortness of breath when ambulating to the bathroom in the hospital, which intervention should the nurse add to the care plan?
- A. Have the child use a bedside commode for elimination.
- B. Administer oxygen after the child uses the bathroom.
- C. Instruct the child to call for assistance when ambulating to the bathroom.
- D. Provide a walker for the child to use when ambulating to the bathroom.
Correct Answer: A
Rationale: Shortness of breath during ambulation may indicate carditis, a serious complication of rheumatic fever. Using a bedside commode minimizes physical exertion, reducing cardiac workload and the risk of worsening symptoms.
You may also like to solve these questions
The nurse correctly advises the adolescent that the brace has to be worn during which time period?
- A. At all times except when bathing
- B. At least 8 hours each day
- C. At night while sleeping
- D. At all times, without exception
Correct Answer: A
Rationale: The Milwaukee brace is typically worn 23 hours a day, except during bathing, to effectively correct scoliosis by maintaining spinal alignment.
If the child weighs 30 kg, what is the hourly flow rate in milliliters? Use the standard 100 mL/kg/day for the first 10 kg of body weight, 50 mL/kg/day for the next 10 kg of body weight, and 20 mL/kg/day for each kilogram above 20 kg of body weight for daily maintenance.
Correct Answer: 70.83 mL/hour
Rationale: Calculation: First 10 kg = 100 mL/kg/day × 10 = 1000 mL/day; Next 10 kg = 50 mL/kg/day × 10 = 500 mL/day; Last 10 kg = 20 mL/kg/day × 10 = 200 mL/day. Total = 1000 + 500 + 200 = 1700 mL/day. Hourly rate = 1700 ÷ 24 = 70.83 mL/hour. Since no exact option is provided, the closest reasonable answer is assumed as correct based on standard practice.
Breech extraction is only indicated in:
- A. Retained second twin.
- B. Footling breech.
- C. Extended breech.
- D. Flexed breech.
- E. Breech in first twin.
Correct Answer: A
Rationale: Breech extraction is indicated for a retained second twin to expedite delivery and prevent complications. Other breech presentations typically require cesarean section or external cephalic version.
The physician orders an I.V. opioid analgesic. Which finding by the nurse would best indicate that the I.V. opioid analgesic is effective?
- A. The respiratory rate is within normal limits.
- B. The child's pain level remains stable.
- C. The child is watching television.
- D. The urine output is 30 mL/hour.
Correct Answer: C
Rationale: A child watching television suggests they are comfortable and distracted from pain, indicating effective pain relief from the opioid. Stable pain levels or normal respiratory rate do not directly confirm pain control.
Which nursing action should be avoided when giving care to a child diagnosed with Wilms' tumor?
- A. Palpating the child's abdomen
- B. Collecting a catheterized urine sample
- C. Assessing pupillary reflex with a penlight
- D. Eliciting a patellar reflex with a reflex hammer
Correct Answer: A
Rationale: Palpating the abdomen in a child with Wilms' tumor risks dislodging tumor cells, potentially causing metastasis, and should be avoided to ensure safety.