Nokea
The nurse is caring for a 4-year-old child who is being hospitalized due to complications from an autoimmune disorder, frequent infections, and a low white blood cell count. This child is very nervous about being in the hospital. Which intervention should the nurse implement to address this child's fears?
- A. Provide the child with a private room
- B. Encourage them to play with other children in the common area
- C. Advise the parents to only visit during visiting hours
- D. Allow the parents to stay as much as they'd like
Correct Answer: D
Rationale: Parental presence reduces fear in a hospitalized child, especially with immune compromise. A private room is ideal but not the focus, group play risks infection, and limited visits increase anxiety.
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The nurse is assisting a client in selecting appropriate food options for dumping syndrome. Which foods would be suitable choices? Select all that apply.
- A. Rice cereal
- B. Pastries
- C. Chicken breast
- D. Cola
- E. Scrambled eggs
Correct Answer: A,C,E
Rationale: Rice cereal, chicken breast, and scrambled eggs are low-sugar, high-protein options suitable for dumping syndrome. Pastries and cola are high-sugar, triggering symptoms.
A school nurse is discussing poison prevention and management with a group of parents. Which statement by parents would indicate a need for additional teaching?
- A. Containers of poisonous liquids need to be properly labeled.
- B. In the event gasoline is ingested by my child, vomiting should be induced.
- C. I may be able to give my child milk or water to dilute a corrosive poison while I rush them to the hospital.
- D. All poisonous materials should be securely stored away from children.
Correct Answer: B
Rationale: Inducing vomiting for gasoline ingestion is dangerous due to aspiration risk. Labeling, diluting corrosives (if advised), and secure storage are correct.
The nurse is caring for a client eight hours following a total thyroidectomy. The nurse plans on obtaining an order to assess the client's serum
- A. potassium level
- B. calcium level
- C. sodium level
- D. glucose level
Correct Answer: B
Rationale: Total thyroidectomy can disrupt parathyroid function, leading to hypocalcemia due to decreased parathyroid hormone. Monitoring serum calcium levels is critical to detect and manage this complication. Potassium, sodium, and glucose levels are less directly affected by thyroidectomy.
The nurse is caring for an infant following a cheiloplasty. Which supply item should the nurse have at the bedside following this procedure?
- A. Nasogastric tube (NGT)
- B. Bottle of sterile water
- C. Suction equipment
- D. Tracheostomy
Correct Answer: C
Rationale: Cheiloplasty is a surgical repair of a cleft lip, which can affect the infant’s ability to feed and maintain a clear airway. Suction equipment is essential at the bedside to clear secretions or blood from the oral cavity, preventing airway obstruction and ensuring airway patency. A nasogastric tube is not typically required unless feeding difficulties are severe. Sterile water is not a priority for immediate postoperative care, and a tracheostomy is not indicated for this procedure.
The nurse is participating in a fall and injury reduction committee to reduce falls in the inpatient environment. Which risk factors in the inpatient environment can be modified through this committee? Select all that apply.
- A. The lighting in the client rooms
- B. Staffing levels
- C. Communication failures
- D. Inadequate client assessment
- E. The prescribing of antihypertensive medications
Correct Answer: A,B,C,D
Rationale: Lighting, staffing, communication, and assessments are modifiable environmental factors. Medication prescribing is a clinical decision.