Nokea
The nurse is caring for a 5-week-old infant presenting with a history of projectile vomiting after feedings. Which additional finding should the nurse expect to assess?
- A. Rebound tenderness in the left lower abdominal quadrant.
- B. Stool that consists of mucus and blood.
- C. Olive-size mass in the epigastric area.
- D. Frequent burping accompanied by poor feeding.
Correct Answer: C
Rationale: An olive-size mass in the epigastric area is characteristic of pyloric stenosis, associated with projectile vomiting.
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The nurse is caring for an adolescent with scoliosis who is recovering after a surgical spinal instrumentation. Which technique should the nurse use when moving this client?
- A. Cross the arms and legs.
- B. Perform a log roll.
- C. Raise the hips.
- D. Flex the knees.
Correct Answer: B
Rationale: The log roll technique maintains spinal alignment, critical after surgical spinal instrumentation.
A child diagnosed with Kawasaki disease is brought to the clinic. The mother reports that her child is irritable, refuses to eat, and has skin peeling on both hands and feet. Which intervention should the nurse instruct the mother to implement first?
- A. Apply lotion to hands and feet.
- B. Encourage the child to rest when possible.
- C. Place the child in a quiet environment.
- D. Make a list of foods that the child likes.
Correct Answer: C
Rationale: A quiet environment reduces sensory stimulation, alleviating irritability, which is a primary concern in Kawasaki disease.
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.
The nurse is giving an intramuscular injection of an antibiotic to a 16-month-old toddler with pneumonia. The toddler does not have any known allergies and has been walking without assistance for one month. Which technique should the nurse select for administration?
- A. Give in the arm, one to 2 inches (2.5 to 5.0 cm) below the acromion process.
- B. Use a needle length of 1/2 inch (1.25 cm) to avoid deep tissue damage.
- C. Administer the injection into the middle of the lateral aspect of the thigh.
- D. Divide the gluteal area into quarters and give IM into the upper outer quadrant.
Correct Answer: C
Rationale: The lateral thigh is the recommended IM injection site for toddlers, minimizing nerve and vessel damage.
The nurse is caring for a child with hypoparathyroidism who demonstrates a carpal spasm when pressure is applied to the upper arm. Which laboratory value should the nurse review?
- A. Potassium.
- B. Chloride.
- C. Sodium.
- D. Calcium.
Correct Answer: D
Rationale: Hypoparathyroidism causes low calcium levels, leading to carpal spasms, so reviewing calcium levels is critical.