Nokea
If the following snacks are available, which one is best to meet the child's need for protein?
- A. Strawberry milkshake
- B. A popsicle stick with cinnamon
- C. Cubes of flavored gelatin
- D. Warmed beef broth
Correct Answer: D
Rationale: Warmed beef broth is a high-protein snack suitable for a burn patient, providing protein needed for tissue repair and wound healing, unlike the other options, which are lower in protein.
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Which assessment finding should the nurse report immediately to the charge nurse or physician?
- A. Clear, watery nasal drainage
- B. Glasgow Coma Scale score of 15
- C. Child does not know the time of day
- D. Apical pulse of 80 beats/minute
Correct Answer: A
Rationale: Clear, watery nasal drainage may indicate cerebrospinal fluid (CSF) leakage, a serious complication of head injury requiring immediate reporting to prevent infection or neurological damage.
Which finding documented by the nurse is most indicative of a client with rheumatic fever?
- A. Slow, irregular heartbeat
- B. Blotchy, diffuse erythema
- C. Decreased antistreptolysin O titer (ASO titer)
- D. Generalized migrating joint tenderness
Correct Answer: D
Rationale: Generalized migrating joint tenderness (polyarthritis) is a hallmark symptom of rheumatic fever, reflecting the inflammatory process affecting multiple joints. An elevated ASO titer (not decreased) would indicate a recent streptococcal infection, and the other options are less specific.
The agitated father of the 12-hour-old newborn reports to the nurse that his baby’s hands and feet are blue. The nurse confirms acrocyanosis and intervenes by taking which action?
- A. Immediately stimulates the infant to cry
- B. Explain that this is normal in a newborn
- C. Assess the newborn’s temperature
- D. Assess the newborn’s cardiac status
Correct Answer: B
Rationale: Acrocyanosis blueness of hands and feet is a normal newborn phenomenon in the first 24 to 48 hours after birth. The nurse should explain this to relieve anxiety. Stimulation temperature or cardiac assessments are unnecessary.
The first-time mother of the 2-hour-old full-term newborn worriedly tells the nurse,“Something black is coming out of my baby.” After determining that the newborn has passed stool which statement by the nurse is most appropriate?
- A. “Black stools could be from bleeding. I will notify your provider now.”
- B. “Breastfeeding will cause all the baby’s stools to be this dark in color.”
- C. “Babies normally pass this type of stool initially; it is called meconium.”
- D. “I’ll check the baby’s temperature; this occurs when babies need warming.”
Correct Answer: C
Rationale: Meconium a greenish-black stool is normal within 24 hours after birth formed from amniotic fluid and intestinal secretions. It’s not related to bleeding breastfeeding or temperature.
If the client asks the nurse for instructions on safe condom use, which information needs to be stressed?
- A. Condoms should be stored in a warm, dry place to prevent damage.
- B. Condoms are generally lubricated with mineral oil or petroleum jelly.
- C. A condom should be applied before the penis becomes erect.
- D. During application, a ½†space should be left at the end of the condom.
Correct Answer: D
Rationale: Leaving a ½†space at the condom's tip prevents breakage by allowing room for semen, a critical aspect of safe condom use to ensure effectiveness.