Nokea
The nurse is admitting a toddler with the diagnosis of near-drowning in a neighbor's heated swimming pool to the emergency department. The nurse should assess the child for:
- A. Hypothermia.
- B. Hypoxia.
- C. Fluid aspiration.
- D. Cutaneous capillary paralysis.
Correct Answer: B,C
Rationale: Near-drowning in a heated pool risks hypoxia from oxygen deprivation and fluid aspiration into the lungs, which are critical to assess.
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A child with spastic cerebral palsy receiving intrathecal baclofen therapy is admitted to the pediatric floor with vomiting and dehydration. The family tells the nurse that they were scheduled to refill the baclofen pump today, but had to cancel the appointment when the child became ill. The nurse should:
- A. Explain that the medication should be discontinued during illness.
- B. Arrange for the pump to be refilled in the hospital.
- C. Reschedule the pump refill for the day of discharge.
- D. Instruct caregivers to call for a refill when the low-volume alarm sounds.
Correct Answer: B
Rationale: Arranging for the pump to be refilled in the hospital ensures continuous therapy, as interrupting baclofen can cause withdrawal symptoms.
The physician orders carbamazepine extended release (Tegretol-XR) for a client with cerebral palsy who also has a seizure disorder. The client has a gastrostomy feeding tube. What should the nurse do?
- A. Crush the medication and administer through the tube.
- B. Request an immediate-release formulation.
- C. Withhold the medication and notify the physician.
- D. Administer the medication orally.
Correct Answer: C
Rationale: Extended-release formulations like Tegretol-XR should not be crushed; the nurse should notify the physician to adjust the order.
A child with a peanut allergy is prescribed an epinephrine auto-injector. The nurse should teach the parents to administer it in which situation?
- A. Mild itching after eating peanuts.
- B. Swelling of the lips and tongue.
- C. Upset stomach after exposure.
- D. Fatigue after a meal.
Correct Answer: B
Rationale: Lip and tongue swelling indicates anaphylaxis, requiring immediate epinephrine. Itching, upset stomach, or fatigue are less severe and managed differently.
When teaching a mother about measures to prevent lead poisoning in her children, which of the following preventive measures should the nurse include as the most effective?
- A. Condemning of old housing developments.
- B. Educating the public on common sources of lead.
- C. Educating the public on the importance of good nutrition.
- D. Keeping pregnant women out of old homes that are being remodeled.
Correct Answer: B
Rationale: Education on lead sources (e.g., paint, dust) empowers families to avoid exposure. Condemning housing is impractical, nutrition is secondary, and protecting pregnant women is less broad-reaching.
When teaching the mother of an infant who has received a temporary colostomy for treatment of Hirschsprung's disease about how the stoma should normally appear, which of the following descriptions about the stoma's appearance should the nurse include in the teaching?
- A. Becoming dark brown in 2 months.
- B. Appearing moist and pink to red.
- C. Drying out within a few weeks.
- D. Shrinking significantly in size.
Correct Answer: B
Rationale: A healthy stoma is moist and pink to red, indicating good blood supply.