The clinic nurse is teaching parents about when to call the office immediately for a child with a fever. What should the nurse include in the teaching session? (Select all that apply.)
- A. The child has a stiff neck.
- B. The fever is over 40.6 C (105 F).
- C. The child is younger than 2 months.
- D. All of the above
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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A child has a central venous access device for intravenous (IV) fluid administration. A blood sample is needed for a complete blood count, hemogram, and electrolytes. What is the appropriate procedure to implement for this blood sample?
- A. Perform a new venipuncture to obtain the blood sample.
- B. Interrupt the IV fluid and withdraw the blood sample needed.
- C. Withdraw a blood sample equal to the amount of fluid in the device, discard, and then withdraw the sample needed.
- D. Flush the line and central venous device with saline and then aspirate the required amount of blood for the sample.
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
The parents of a child with acute postinfectious glomerulonephritis (APIGN) ask how they will know that the condition is improving. How should the nurse respond?
- A. Your child's urine output will increase, and the urine will become less brown in color.
- B. Your child will rest more comfortably.
- C. Your child's appetite will decrease.
- D. Your child's laboratory test values will show increased BUN.
Correct Answer: A
Rationale: Improvement in APIGN is indicated by an increase in urine output and a change in urine color from brown (due to hematuria) to a more normal appearance. This reflects a reduction in glomerular inflammation and improved kidney function. Choice B is incorrect because resting more comfortably is not a direct indicator of kidney function improvement. Choice C is incorrect because a decrease in appetite is not typically associated with improvement in APIGN. Choice D is incorrect because an increased BUN value would suggest worsening kidney function rather than improvement.
The parent of a 3-month-old infant is concerned because the infant is not able to sit independently. How should the nurse respond to this parent's concern?
- A. Sitting ability and the age of first tooth eruption are not correlated.
- B. Most infants sit steadily at 4 months.
- C. Most infants sit steadily at 3 months.
- D. Most infants do not sit steadily until 6-8 months.
Correct Answer: D
Rationale: The correct answer is D because sitting steadily typically occurs closer to 6-8 months of age, not 3 or 4 months. Choice A is incorrect because sitting ability and the age of first tooth eruption are not related. Choice B and C are incorrect as most infants do not sit steadily at 3 or 4 months, and it is more common for infants to achieve this milestone around 6-8 months.
What are classified as hydrocarbon poisons?
- A. All below
- B. Gasoline
- C. Turpentine
- D. Lighter fluid
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A father calls the clinic because he found his young daughter squirting Visine eyedrops into her mouth. What is the most appropriate nursing action?
- A. Reassure the father that Visine is harmless.
- B. Direct him to seek immediate medical treatment.
- C. Recommend inducing vomiting with ipecac.
- D. Advise him to dilute Visine by giving his daughter several glasses of water to drink.
Correct Answer: B
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.