Nokea
Immediately on return to the nursing unit after surgical repair of a cleft palate, in which of the following positions should the nurse place the child?
- A. On the back with the head in a position of comfort.
- B. In low Fowler's position with the head turned to the side.
- C. Lying on the abdomen with the head turned to the side.
- D. In reverse Trendelenburg with the head tilted forward.
Correct Answer: C
Rationale: Lying on the abdomen with the head turned to the side facilitates drainage and reduces the risk of aspiration post-surgery.
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A 9-month-old child with cystic fibrosis does not like to take a pancreatic enzyme supplement with meals and snacks. The mother does not like to force the child to take the supplement. The most important reason for the child to take the pancreatic enzyme supplement with meals and snacks is:
- A. The child will become dehydrated if the supplement is not taken with meals and snacks.
- B. The child needs these pancreatic enzymes to help the digestive system absorb fats, carbohydrates, and proteins.
- C. The child needs the pancreatic enzymes to aid in liquefying mucus to keep the lungs clear.
- D. The child will experience severe diarrhea if the supplement is not taken as prescribed.
Correct Answer: B
Rationale: Pancreatic enzyme supplements are essential in cystic fibrosis to aid digestion and absorption of fats, carbohydrates, and proteins, compensating for pancreatic insufficiency.
The nurse should teach the mother of a child who has a new cast for a fractured radius to do which of the following for the first few days at home?
- A. Use a hair dryer to dry the cast more quickly.
- B. Have the child refrain from strenuous activities.
- C. Check movement and sensation of the child's fingers once a day.
- D. Administer acetaminophen every 8 to 12 hours for discomfort.
Correct Answer: B
Rationale: Refraining from strenuous activities prevents damage to the cast and supports healing during the initial recovery period.
The nurse reports to the physician signs of increased intracranial pressure in an infant with a myelomeningocele who has which of the following?
- A. A high-pitched cry.
- B. Overflow voiding only.
- C. A fontanel that bulges with crying.
Correct Answer: A
Rationale: A high-pitched cry is a classic sign of increased intracranial pressure in infants, indicating neurological distress. Overflow voiding and a fontanel bulging only with crying are less specific.
An adolescent with a history of losing weight and fatigue is admitted to the hospital with a diagnosis of stage I chronic renal failure. Based on these fi ndings, the nurse should:The chart shows:
- A. Continue monitoring intake and output.
- B. Notify the physician.
- C. Restrict the client’s fluids.
- D. Increase the client’s fluids.
Correct Answer: B
Rationale: The nurse would expect a person with a normal GFR to have approximately equal inputs and outputs. Chronic renal failure has fi ve stages. In stage I the glomerular fi ltration rate (GFR) is approximately ≥90 mL/minute/1.73 m2. In stage II the GFR decreases to approximately 60 to 89 mL/minute/1.73 m2. The decreased urine output may indicate worsening disease and should be reported. Assessing the client’s intake and output is still important, but notifying the provider is the priority. Fluids are restricted based on decreased sodium. Clients are encouraged to drink to thirst. Therefore, there is not enough information to suggest increasing or restricting fl uids.
The health care provider has ordered a sterile urine specimen on a 3-year-old boy with a history of recurrent urinary tract infections. The family is upset because the last time the child was catheterized the procedure was very painful and traumatic. The nurse should tell the family:
- A. I will request an order for a sedative to help him relax.
- B. I can't do anything to reduce the pain
- C. but you can hold him during the procedure.
- D. I will get an order for a lidocaine-based lubricant to make the procedure more comfortable.
- E. I can apply a topical anesthetic 20 minutes before placing the catheter.
Correct Answer: D
Rationale: Topical anesthetics can minimize discomfort.