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The caregiver discovers a 6-month-old infant unresponsive and calls for help. After opening the airway and finding the infant is still not breathing, what action should the caregiver take?
- A. Palpate femoral pulse and check for regularity.
- B. Deliver cycles of 30 chest compressions and 2 breaths.
- C. Give two breaths that make the chest rise.
- D. Feel the carotid pulse and check for adequate breathing.
Correct Answer: C
Rationale: Providing two breaths that make the chest rise is the correct action in this situation. This helps to deliver oxygen to the infant's lungs and body, which is crucial in a situation where the infant is not breathing. Chest rise indicates successful ventilation, and it is an essential step in pediatric resuscitation, especially for infants.
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A child with leukemia is admitted for chemotherapy, and the nursing diagnosis 'altered nutrition, less than body requirements related to anorexia, nausea, and vomiting' is identified. Which intervention should the nurse include in this child's plan of care?
- A. Encourage a variety of large portions of food at every meal.
- B. Allow the child to eat any food desired and tolerated.
- C. Recommend eating the food as siblings eat at home.
- D. Restrict food brought from fast food restaurants.
Correct Answer: B
Rationale: Allowing the child to eat any food desired and tolerated is the most appropriate intervention for a child with altered nutrition due to anorexia, nausea, and vomiting. It is crucial to prioritize maintaining adequate nutritional intake, and by allowing the child to choose foods they desire and can tolerate, the chances of improving their nutritional status increase. This approach helps in ensuring that the child receives necessary nutrients during chemotherapy, even if their appetite is affected by the treatment.
A 10-year-old girl who has had type 1 diabetes mellitus (DM) for the past two years tells the nurse that she would like to use a pump instead of insulin injections to manage her diabetes. Which assessment of the girl is most important for the nurse to obtain?
- A. Understanding of the quality control process used to troubleshoot the pump
- B. Interpretation of fingerstick glucose levels that influence diet selections
- C. Knowledge of her glycosylated hemoglobin A1c levels for the past year
- D. Ability to perform the pump for basal insulin with mealtime boluses
Correct Answer: A
Rationale: In a patient transitioning to an insulin pump, understanding the quality control process to troubleshoot the pump is essential for ensuring proper and safe management of diabetes. This knowledge enables the individual to identify and address any issues that may arise with the pump, helping maintain optimal glycemic control and prevent complications.
A child who is admitted to the hospital with anemia is anxious, fearful, and hyperventilating. The nurse anticipates the child developing which acid-base imbalance?
- A. Metabolic acidosis
- B. Respiratory acidosis
- C. Respiratory alkalosis
- D. Metabolic alkalosis
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A 4-month-old girl is brought to the clinic by her mother because she has had a cold for 2 or 3 days and woke up this morning with a hacking cough and difficulty breathing. Which additional assessment finding should alert the nurse that the child is in acute respiratory distress?
- A. Bilateral bronchial breath sounds.
- B. Diaphragmatic respiration.
- C. A resting respiratory rate of 35 breaths per minute.
- D. Flaring of the nares.
Correct Answer: D
Rationale: Flaring of the nares is a classic sign of acute respiratory distress in infants. It indicates increased work of breathing and is a visible cue that the child is struggling to breathe. This finding should alert healthcare providers to the severity of the respiratory distress and the need for prompt intervention to support the child's breathing.
What instructions should the nurse provide to the parents about the treatment of head lice in a 3-year-old boy who has been confirmed to have head lice?
- A. Wash the child's bed linens and clothing in hot soapy water.
- B. Dispose of the child's brushes, combs, and other hair accessories.
- C. Rewash the child's hair following a 24-hour isolation period.
- D. Take the child to a hair salon for a shampoo and shorter haircut.
Correct Answer: A
Rationale: The correct instruction for the nurse to provide to the parents is to wash the child's bed linens and clothing in hot soapy water. This is essential to eliminate head lice as they can survive on bedding and clothing. It is also important to wash any other items that the child may have used or come into contact with, such as brushes and combs, to prevent reinfestation. Rewashing the child's hair following an isolation period is not necessary, and taking the child to a hair salon for a shampoo and shorter haircut is not a recommended treatment for head lice.