Nokea
The nurse caring for a 7 -year-old child who has undergone a cardiac catheterization 2 hours ago finds the dressing and bed saturated with blood. The nurse should first:
- A. Assess the vital signs.
- B. Reinforce the dressing.
- C. Apply pressure just above the catheter insertion.
- D. Notify the physician.
Correct Answer: C
Rationale: Direct pressure is the first measure that should be used to control bleeding. Taking the vital signs will not control the bleeding. This should be done while another person is being sent to notify the physician. The dressing can be reinforced after the bleeding has been contained.
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Which of the following should the nurse use to determine achievement of the expected outcome for an infant with severe diarrhea and a nursing diagnosis of Deficient fluid volume related to passage of profuse amounts of watery diarrhea?
- A. Moist mucous membranes.
- B. Passage of a soft, formed stool.
- C. Absence of diarrhea for a 4-hour period.
- D. Ability to tolerate intravenous fluids well.
Correct Answer: A
Rationale: Moist mucous membranes indicate adequate hydration, the goal of treatment.
A child with nephrosis is taking prednisone. The nurse should teach the caregivers to report which of the following adverse effects? Select all that apply.
- A. Increased urinary output.
- B. Hematemesis.
- C. Respiratory infection.
- D. Bleeding gums.
- E. Vision problems.
Correct Answer: B,C,D,E
Rationale: These symptoms indicate potential complications.
The nurse is admitting a child who has been diagnosed with bacterial meningitis to the pediatric unit. The nurse should implement which type of isolation?
- A. Standard precautions.
- B. Contact precautions.
- C. Airborne precautions.
- D. Droplet precautions.
Correct Answer: D
Rationale: Bacterial meningitis, such as meningococcal, requires droplet precautions due to transmission via respiratory secretions.
When assessing a 2-year-old child brought by his mother to the clinic for a routine checkup, which of the following should the nurse expect the child to be able to do?
- A. Ride a tricycle.
- B. Tie his shoelaces.
- C. Kick a ball forward.
- D. Use blunt scissors.
Correct Answer: C
Rationale: Kicking a ball forward is a gross motor skill expected at 2 years.
Which of the following statements made by the mother of a school-age child who has had a craniotomy for a brain tumor would warrant further exploration by the nurse?
- A. After this, I'll never let her out of my sight again.'
- B. I hope that she'll be able to go back to school soon.'
- C. I wonder how long it will be before she can ride her bike.'
- D. Her best friend is eager to see her; I hope she won't be upset.'
Correct Answer: A
Rationale: Overprotectiveness may indicate anxiety or maladaptive coping, requiring further exploration to support the mother's emotional adjustment.