Nokea
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.
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An adolescent sustains a T3 spinal cord injury. After insertion of an intravenous line, a nasogastric tube, and an indwelling urinary (Foley) catheter, the adolescent is admitted to the intensive care unit. What should the nurse do next when assessment reveals that the adolescent's feet and legs are cool to the touch?
- A. Cover the adolescent's legs with blankets.
- B. Report this finding to the physician immediately.
- C. Reposition the adolescent's legs.
- D. Lay the adolescent flat to aid circulation.
Correct Answer: A
Rationale: Cool extremities indicate poor circulation, common in spinal cord injury; covering with blankets promotes warmth and comfort.
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.
After teaching a child with leukemia scheduled for a bone marrow aspiration about the procedure, the nurse determines that the teaching has been successful when the child identifies which of the following as the site for the aspiration?
- A. Right lateral side of the right wrist.
- B. Middle of the chest.
- C. Distal end of the thigh.
- D. Back of the hipbone.
Correct Answer: D
Rationale: Bone marrow aspiration is typically performed at the iliac crest (hipbone). Other sites are incorrect.
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.
When observing the parent instilling prescribed ear drops ordered twice a day for a toddler, the nurse decides that the teaching about positioning of the pinna for instillation of the drops is effective when the parent pulls the toddler's pinna in which of the following directions?
- A. Up and forward.
- B. Up and backward.
- C. Down and forward.
- D. Down and backward.
Correct Answer: D
Rationale: In children under 3, the pinna is pulled down and back to straighten the ear canal.