Nokea
The nurse is caring for a child in Bryant’s traction (see fi gure). The nurse should:
- A. Adjust the weights on the legs until the buttocks rest on the bed.
- B. Provide frequent skin care.
- C. Place a pillow under the buttocks.
- D. Remove the elastic leg wraps every 8 hours for 10 minutes.
Correct Answer: B
Rationale: The traction is positioned correctly; the nurse should provide frequent skin care to the back and shoulder areas. The hips and buttocks should be lifted off the bed to provide counter traction; the nurse should not adjust the weights. The nurse should not place a pillow under the buttocks as this would prevent counter traction. The elastic wraps should remain on the legs unless permitted by the physician.
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Which of the following assessments would be most important for the nurse to make initially in a school-age child being seen in the clinic who has a sore throat, muscle tenderness, arms feeling weak, and generally is not feeling well?
- A. Difficulty swallowing.
- B. Recent history of viral infection.
- C. Presence of fever.
- D. History of recent trauma.
Correct Answer: A
Rationale: Difficulty swallowing indicates potential cranial nerve involvement, a critical early sign in Guillain-Barré syndrome, requiring immediate attention.
A 14-year-old girl with sickle cell disease has her fourth hospitalization for sickle cell crisis. Her family is planning a ski vacation in the mountains. What should the nurse tell the parents?
- A. Encourage them to go on the trip.
- B. Go on the trip, but find a sitter for the 14-year-old.
- C. Suggest the trip be postponed until next year.
- D. Explain that the high altitude may cause a crisis.
Correct Answer: D
Rationale: High altitudes reduce oxygen availability, increasing the risk of sickle cell crisis due to hypoxia. This is a critical consideration for the child's safety.
When developing the discharge plan for a child who had a nephrectomy for a Wilms' tumor, the nurse identifies outcomes to prevent damage to the child's remaining kidney and accomplish which of the following?
- A. Minimize pain.
- B. Prevent dependent edema.
- C. Prevent urinary tract infection.
- D. Minimize sodium intake.
Correct Answer: C
Rationale: Preventing UTIs protects kidney function.
An 18-month-old with a congenital heart defect is to receive digoxin twice a day. The nurse should instruct the parents about which of the following?
- A. Digoxin enables the heart to pump more effectively with a slower and more regular rhythm.
- B. Signs of toxicity include loss of appetite, vomiting, increased pulse, and visual disturbances.
- C. Digoxin is absorbed better if taken with meals.
- D. If the child vomits within 15 minutes of administration, the dosage should be repeated.
Correct Answer: A
Rationale: Digoxin improves heart function by increasing contractility and regulating rhythm. Toxicity signs are correct but not the focus here, absorption is not meal-dependent, and repeating a vomited dose risks overdose.
When developing the teaching plan for parents using the Pavlik harness with their child, what should be the nurse's initial step?
- A. Assessing the parents' current coping strategies.
- B. Determining the parents' knowledge about the device.
- C. Providing the parents with written instructions.
- D. Giving the parents a list of community resources.
Correct Answer: B
Rationale: Determining the parents' knowledge about the Pavlik harness is the initial step to tailor teaching to their understanding and needs.