Nokea
What is a 1-year-old with history of UTIs and diagnosed with vesicoureteral reflux s tachycardia at risk for?
- A. Nephrotic syndrome
- B. Renal Scarring
- C. Polycystic kidney
- D. Acute glomerulonephritis
- E. Pyclonephritis
Correct Answer: B,E
Rationale: The correct answers for a 1-year-old with history of UTIs and diagnosed with vesicoureteral reflux at risk for are B: Renal Scarring and E: Pyelonephritis. Vesicoureteral reflux increases the risk of recurrent UTIs, leading to pyelonephritis. Renal scarring can result from repeated pyelonephritis episodes. Nephrotic syndrome (A) is not typically associated with UTIs or reflux. Polycystic kidney (C) is a congenital condition, not related to the scenario. Acute glomerulonephritis (D) is usually caused by post-streptococcal infection, not UTIs.
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Which of the following findings should the nurse identify as a manifestation of severe dehydration?
- A. Capillary refill time 3 seconds
- B. Sunken anterior fontanel
- C. Weight loss of 5%
- D. Produces tears when crying
Correct Answer: B
Rationale: The correct answer is B: Sunken anterior fontanel. This finding is indicative of severe dehydration in infants, as it suggests significant fluid loss and decreased tissue turgor. A sunken fontanel is a late sign of dehydration. Choice A is incorrect as a capillary refill time of 3 seconds is within normal limits. Choice C may be seen in mild to moderate dehydration, but severe dehydration would involve a greater weight loss. Choice D is not specific to dehydration, as tear production can still occur even in cases of dehydration.
Which of the following information should the nurse include in the teaching?
- A. Provide for periods of rest.
- B. Increase the child's oxygen flow rate until the child no longer has cyanosis.
- C. Withhold digoxin if the child's pulse is greater than 100/min.
- D. Weigh the child once each month.
Correct Answer: A
Rationale: Correct Answer: A - Provide for periods of rest.
Rationale: It is important for the nurse to include information about providing periods of rest in the teaching because rest is essential for recovery and healing. Rest allows the body to conserve energy, reduce stress, and promote overall well-being. By including this information, the nurse is promoting the child's health and supporting the healing process.
Summary of other choices:
B: Increasing oxygen flow rate until cyanosis resolves can lead to oxygen toxicity and is not a safe or appropriate intervention.
C: Withholding digoxin based solely on pulse rate without considering other factors or consulting the healthcare provider can be dangerous and potentially harmful.
D: Weighing the child once a month is important for monitoring growth and nutrition, but it is not directly related to the immediate care and teaching needed in this scenario.
Which of the following actions should the nurse take first?
- A. Check the pH of the gastric secretions.
- B. Set the administration rate on the feeding pump.
- C. Flush the tube with water.
- D. Attach the feeding bag tubing to the end of the NG tube.
Correct Answer: C
Rationale: The nurse should first flush the tube with water to ensure patency and prevent clogging. This step clears any residual medication or debris, allowing for safe and effective administration of feedings. Checking the pH of gastric secretions (A) is important but can be done after ensuring tube patency. Setting the administration rate (B) and attaching the feeding bag tubing (D) are premature without confirming tube patency. The correct order prioritizes patient safety and optimal feeding delivery.
Which of the following laboratory findings should the nurse expect?
- A. Decreased prothrombin time
- B. Increased Hgb level
- C. Increased RBC
- D. Decreased platelet count
Correct Answer: D
Rationale: The correct answer is D: Decreased platelet count. This is expected in a patient with thrombocytopenia, which is a condition characterized by low platelet levels. Thrombocytopenia can lead to abnormal bleeding and bruising due to impaired blood clotting.
A: Decreased prothrombin time would not be expected in thrombocytopenia, as it measures the clotting ability of the plasma, not platelets.
B: Increased Hgb level and C: Increased RBC levels are not typically associated with thrombocytopenia.
In summary, a decreased platelet count is the most relevant laboratory finding to expect in a patient with thrombocytopenia.
Which of the following is an appropriate action for the nurse to take to deliver atraumatic care?
- A. Apply eutectic mixture of local anesthetics (EMLA) cream immediately before the injections.
- B. Provide a pacifier coated with an oral sucrose solution prior to the injections.
- C. Inject the immunizations into the deltoid muscle.
- D. Use a 20-gauge needle for the injections.
Correct Answer: B
Rationale: The correct answer is B: Provide a pacifier coated with an oral sucrose solution prior to the injections. This is an appropriate action for atraumatic care because it helps to reduce pain and distress during procedures, such as injections, by utilizing non-pharmacological comfort measures. The sucrose solution on the pacifier helps to soothe and distract the child, making the experience less traumatic.
Choice A (Apply EMLA cream immediately before injections) is incorrect because while EMLA cream numbs the skin, it does not address the psychological aspect of pain and distress associated with procedures.
Choice C (Inject the immunizations into the deltoid muscle) is incorrect because the location of injection does not directly relate to atraumatic care.
Choice D (Use a 20-gauge needle for the injections) is incorrect because the size of the needle does not address the psychological comfort of the child during the procedure.