Nokea
Informed consent for a minor guarantees that the parent or legal guardian understands what aspect(s) of a procedure?
- A. Purpose of the procedure
- B. Risks associated with the procedure
- C. That no suit can be brought for damages
- D. That the document must be signed and witnessed
- E. That information was given
Correct Answer: A,B,D,E
Rationale: Informed consent ensures understanding of the procedure's purpose, risks, information provided, and the need for a signed, witnessed document.
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Which intervention is correct when a nurse is administering a gastrostomy feeding by gravity?
- A. Discard the residual and increase the volume of feeding by the amount of residual.
- B. Flush the gastrostomy tube with 2 to 4 ounces of water before the feeding.
- C. Refill the syringe with formula after it has completely emptied.
- D. Position the child on the right side after a feeding.
Correct Answer: D
Rationale: Positioning on the right side after feeding promotes gastric emptying and prevents regurgitation.
Which intervention will the nurse implement when suctioning a tracheostomy?
- A. Suction for two to three breaths.
- B. Clear the catheter with water after suctioning for reuse.
- C. Apply suction for no more than 15 seconds.
- D. Establish a regular schedule for suctioning.
Correct Answer: C
Rationale: Limiting suction to 15 seconds prevents hypoxia and tissue damage during tracheostomy suctioning.
Which patient assessment requires immediate intervention?
- A. Toddler with an axillary temperature of 99?°F
- B. School-age child with widening pulse pressure
- C. Infant pulse rate of 100 beats/minute
- D. Adolescent with a respiratory rate of 28 breaths/minute
Correct Answer: B
Rationale: Widening pulse pressure may indicate increased intracranial pressure, requiring immediate intervention.
What statement made by the adolescent led the nurse to determine she understood the instructions?
- A. I should wash my perineum with soap and water, then begin to urinate.'
- B. I clean the perineum from front to back with an antiseptic wipe before I urinate.'
- C. I'll collect the first stream of urine in a sterile container.'
- D. I will discard the first void and collect a freshly voided specimen 30 minutes later.'
Correct Answer: B
Rationale: Cleaning the perineum from front to back with an antiseptic wipe ensures a clean-catch urine specimen.
What factor does the nurse explain affects the infant's physiological response to medications?
- A. Faster metabolism in the liver
- B. Slower intestinal transit
- C. Immature kidney function
- D. Increased secretion of hydrochloric acid
Correct Answer: C
Rationale: Immature kidney function in infants under 1 year hinders effective drug excretion, affecting response.