Nokea
Shortly after an infant is returned to his room following hydrocele repair, the infant's mother tells the nurse that the child's scrotum looks swollen and bruised. Which of the following responses by the nurse would be most appropriate?
- A. Let me see if the doctor has ordered aspirin for him. If he did
- B. I'll get it right away.
- C. Why don't you wait in his room? Then you can ask me any questions when I get there.
- D. What you are describing is unusual after this type of surgery. I'll let the doctor know.
- E. This is normal after this type of surgery. Let's look at it together just to be sure.
Correct Answer: D
Rationale: Swelling and bruising post-surgery are common.
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Which of the following should the nurse include when teaching the father of an infant just admitted with gastroenteritis about initial treatment for his infant?
- A. The infant will receive no liquids by mouth.
- B. Intravenous antibiotics will be started.
- C. The infant will be placed in a mist tent.
- D. An iron-fortified formula will be used.
Correct Answer: A
Rationale: NPO status is common initially to rest the gut during rehydration.
A 4-year-old has been scheduled for a cardiac catheterization. To help prepare the family the nurse should:
- A. Advise the family to bring the child to the hospital the night before.
- B. Explain that the child will need a large bandage after the procedure.
- C. Discourage bringing favorite toys that might become associated with pain.
- D. Explain that the child may get up as soon as the vital signs are stable.
Correct Answer: B
Rationale: The catheter insertion site will be covered with a bandage. This is important for preschool children to know as they are very concerned about bodily harm. Preparing the child the night before, bringing favorite toys, and explaining activity restrictions are also important but not the primary focus of this choice.
A transfusion of packed red blood cells has been ordered for a 1-year-old with sickle cell anemia. The infant has a 25 gauge I.V. infusing dextrose with sodium and potassium. Using the Situation, Background, Assessment, Recommendation (SBAR) method of communication, the nurse contacts the physician and recommends:
- A. Starting a second I.V. with a 22 gauge catheter to infuse normal saline with the blood.
- B. Using the existing I.V., but changing the fluids to normal saline for the transfusion.
- C. Replacing the I.V. with a 22 gauge catheter to infuse the ordered fluids.
- D. Starting a second I.V. with a 25 gauge catheter to infuse normal saline with the transfusion.
Correct Answer: A
Rationale: A second I.V. with a larger 22-gauge catheter ensures safe blood transfusion, as dextrose is incompatible and a 25-gauge is too small.
What should be part of the nurse's teaching plan for a child with epilepsy being discharged on a regimen of diphenylhydantoin (Dilantin)?
- A. Drinking plenty of fluids.
- B. Brushing teeth after each meal.
- C. Having someone be with the child during waking hours.
- D. Reporting signs of infection.
Correct Answer: B
Rationale: Dilantin can cause gingival hyperplasia; brushing after meals promotes oral hygiene to mitigate this side effect.
The mother of a 2-year-old is concerned because the child's right eye seems to turn in toward his nose when he is tired. The nurse should:
- A. Assure the mother that this is a normal event when the child is tired.
- B. Advise the mother to continue to watch his eyes closely and if the problem persists to call the clinic.
- C. Test the child with the cover-uncover test and refer to an ophthalmologist if the test is abnormal.
- D. Explain to the mother that the child will probably outgrow the weakness and she need not be concerned.
Correct Answer: C
Rationale: The cover-uncover test can detect strabismus, which requires referral if confirmed.