Nokea
The nurse is administering gastrostomy feedings to an infant after surgery to correct a tracheoesophageal fistula (TEF). To prevent air from entering the stomach once the syringe barrel is attached to the gastrostomy tube the nurse should:
- A. Unclamp the tube after pouring the complete amount of formula to be administered into the syringe barrel.
- B. Pour all of the formula to be administered into the syringe barrel after opening the clamp.
- C. Maintain a continuous flow of formula down the side of the syringe barrel once the clamp is opened.
- D. Move small amount of formula to enter the stomach before pouring more formula into the syringe barrel.
Correct Answer: D
Rationale: Allowing small amounts of formula to enter before adding more prevents air from being trapped in the tube.
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The nurse assesses a 6-month-old for vaccination readiness. Which finding would most likely indicate the need to delay administering the diphtheria, tetanus, and acellular pertussis (DTaP) vaccine?
- A. A family history of sudden infant death syndrome (SIDS).
- B. A fever of 38.5°C following the 4-month vaccinations.
- C. An acute bilateral ear infection.
- D. Living with a family member who is immunosuppressed.
Correct Answer: C
Rationale: An acute infection is a contraindication for vaccination due to the risk of adverse reactions.
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.
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.
After the nurse teaches the mother of a child with atopic dermatitis how to bathe her child, which of the following statements by the mother indicates effective teaching?
- A. I let my child play in the tub for 30 minutes every night.
- B. I would loves the bubble bath I put in the tub.
- C. When my child gets out of the tub I just pat the skin dry.
- D. I make sure my child has a bath every night.
Correct Answer: C
Rationale: Patting the skin dry prevents irritation and maintains skin integrity in atopic dermatitis. Prolonged baths, bubble baths, and daily bathing can exacerbate dryness and irritation.
While the nurse is delivering abdominal thrusts to a 6-year old who is choking on a foreign body, the child begins to cry. Which of the following should the nurse do next?
- A. Tap or gently shake the shoulders.
- B. Deliver back slaps.
- C. Perform a blind finger sweep of the mouth.
- D. Observe the child closely.
Correct Answer: D
Rationale: If the child begins to cry, it indicates the airway is no longer obstructed, as crying requires airflow. The nurse should observe the child closely to ensure stability.