Nokea
The nurse determines that interventions for decreasing fluid retention have been effective when the child with nephrotic syndrome demonstrates evidence of which of the following?
- A. Decreased abdominal girth.
- B. Increased caloric intake.
- C. Increased respiratory rate.
- D. Decreased heart rate.
Correct Answer: A
Rationale: Decreased girth indicates reduced edema.
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Which of the following actions indicates that the parents of a 12-month-old with iron deficiency anemia understand how to administer iron supplements?
- A. They administer iron supplements in combination with fruit juice.
- B. They administer iron supplements with meals.
- C. They report dark stools.
- D. They brush the child's teeth after administering the iron supplements.
- E. They decrease dietary intake of foods fortified with iron.
Correct Answer: A,C,D
Rationale: Iron with fruit juice enhances absorption, dark stools are expected, and brushing teeth prevents staining. Iron with meals reduces absorption, and fortified foods should not be decreased.
The nurse is assessing a child with sickle cell disease during a routine clinic visit. Which finding requires immediate follow-up by the nurse?
- A. Pallor of the nail beds and mucous membranes.
- B. A heart rate of 88 beats per minute.
- C. Intact and equal bilateral peripheral pulses.
- D. Normal vision and hearing reported by the parents.
Correct Answer: A
Rationale: Pallor of nail beds and mucous membranes indicates anemia or poor perfusion, a serious concern in sickle cell disease requiring immediate follow-up.
Which intervention should the nurse prioritize for an infant with failure to thrive?
- A. Administer IV fluids.
- B. Establish a feeding schedule.
- C. Order a developmental evaluation.
- D. Increase room temperature.
Correct Answer: B
Rationale: A consistent feeding schedule addresses poor intake, promoting weight gain. IV fluids are for acute dehydration, developmental evaluation is secondary, and room temperature is less relevant.
The nurse is preparing an infant for inguinal hernia repair. Which preoperative intervention is most important?
- A. Administering a sedative.
- B. Ensuring NPO status.
- C. Applying a warm compress.
- D. Checking for allergies.
Correct Answer: B
Rationale: NPO status is critical to prevent aspiration during anesthesia.
A nurse is assessing an 8-year-old with diabetes who is experiencing hyperglycemia. Which symptom[s] indicate(s) that the hyperglycemia requires immediate intervention? Select all that apply.
- A. Weakness.
- B. Thirst.
- C. Shakiness.
- D. Hunger.
- E. Headache.
- F. Irritability.
- G. Dizziness.
Correct Answer: B,E,F
Rationale: Thirst, headache, and irritability are hallmark symptoms of hyperglycemia progressing to diabetic ketoacidosis, requiring immediate intervention. Weakness, shakiness, hunger, and dizziness suggest hypoglycemia instead.