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The nurse is assessing the lung sounds of a preschooler. Which action should the nurse implement to ensure the child's cooperation?
- A. Have the child blow a cotton ball and have the parent catch it.
- B. Place a toy in the child's hands while listening to the breath sounds.
- C. Offer the child bubbles before the stethoscope is placed.
- D. Allow the child to use a stethoscope on a stuffed animal.
Correct Answer: D
Rationale: Allowing the child to use a stethoscope on a stuffed animal familiarizes them with the procedure, increasing cooperation.
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Which snack selected by a school-aged child with gastroesophageal reflux indicates to the nurse that the child understands the dietary restrictions?
- A. Sugar cookies.
- B. Pizza.
- C. Tacos.
- D. Chocolate milkshake.
Correct Answer: A
Rationale: Sugar cookies are low-fat and low-sugar, suitable for gastroesophageal reflux, unlike high-fat or acidic options.
The nurse is caring for an adolescent with type 1 diabetes mellitus presenting with an HbA1c of 11% (97 mmol/mol), thirst, and blurred vision. Which action should the nurse take first?
- A. Review prior insulin prescriptions.
- B. Obtain point-of-care glucose.
- C. Assess urine for ketones.
- D. Check blood pressure.
Correct Answer: B
Rationale: Obtaining a point-of-care glucose reading is the first step to assess current blood glucose levels, given symptoms suggestive of hyperglycemia.
The nurse observes a mother giving her 11-month-old ferrous sulfate (iron drops), followed by 2 ounces (60 mL) of orange juice. What should the nurse do next?
- A. Suggest placing the iron drops in the orange juice and then feeding the infant.
- B. Give the mother positive feedback about the way she administered the medication.
- C. Instruct the mother to feed the infant nothing for 30 minutes after giving the iron drops.
- D. Tell the mother to follow the iron drops with infant formula instead of orange juice.
Correct Answer: B
Rationale: Giving orange juice after iron drops enhances iron absorption due to vitamin C, so positive feedback is appropriate.
During a routine clinic visit, the nurse determines that a 5-year-old girl's systolic blood pressure is greater than the 90th percentile. Which action should the nurse implement next?
- A. Refer the child to the healthcare provider and schedule evaluation of blood pressure in two weeks.
- B. Measure the child's blood pressure three times during the visit and determine the highest of the readings.
- C. Conduct a head-to-toe assessment and omit repeated blood pressures during the examination.
- D. Take the blood pressure two more times during the visit and determine the average of the three readings.
Correct Answer: D
Rationale: Taking the blood pressure two more times and averaging the readings provides a more accurate assessment.
A newborn with a repaired gastroschisis is transferred to the paediatric unit after several days in the paediatric intensive care unit. The infant is receiving parenteral nutrition and continuous enteral feedings. To maintain normal growth and development of the infant, which action should the nurse include in the plan of care?
- A. Offer a pacifier for non-nutritive sucking.
- B. Use sterile technique during feedings.
- C. Ensure placement of the enteral tube with an abdominal x-ray.
- D. Speak to the healthcare provider about instituting physical therapy.
Correct Answer: A
Rationale: Non-nutritive sucking via a pacifier promotes oral motor skill development, supporting normal feeding behaviors critical for growth.