Nokea
The nurse is caring for a child who has just returned from surgery for repair of a cleft lip. In which order, from first to last, should the nurse do the following?
- A. Maintain a clear and adequate airway.
- B. Maintain sufficient fluid and caloric intake.
- C. Provide emotional comfort to the child.
- D. Apply elbow restraints.
- E. Teach the parents proper feeding methods.
Correct Answer: A,B,C,D,E
Rationale: Postoperative care prioritizes airway maintenance to ensure breathing, followed by fluid and caloric intake for recovery, emotional comfort to reduce stress, elbow restraints to protect the surgical site, and finally teaching parents feeding methods for ongoing care.
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A toddler is brought to the emergency room after ingesting an undetermined amount of drain cleaner. The nurse should expect to assist with which of the following first?
- A. Administering an emetic.
- B. Performing a tracheostomy.
- C. Performing gastric lavage.
- D. Inserting an indwelling urinary (Foley) catheter.
Correct Answer: C
Rationale: Gastric lavage is the priority to remove the corrosive substance from the stomach, preventing further damage. Emetics are contraindicated for corrosives as they can worsen injury. Tracheostomy may be needed later for airway issues, and a urinary catheter is not relevant initially.
To assess the development of a 1-month-old, the nurse asks the parent if the infant is able to:
- A. Smile and laugh out loud.
- B. Roll from back to side.
- C. Hold a rattle briefly.
- D. Turn the head from side to side.
Correct Answer: D
Rationale: A 1-month-old can turn their head side to side, a basic motor milestone.
When teaching the parents of a child with a ventricular septal defect who is scheduled for a cardiac catheterization, the nurse explains that this procedure involves the use of which of the following?
- A. Ultra-high-frequency sound waves.
- B. Catheter placed in the right femoral vein.
- C. Cutdown procedure to place a catheter.
- D. General anesthesia.
Correct Answer: B
Rationale: Cardiac catheterization involves inserting a catheter, typically through the femoral vein, to assess heart structures. Ultra-high-frequency sound waves are used in echocardiography, a cutdown is not standard, and general anesthesia is not always required.
During a developmental screening, the nurse finds that a 3-year-old child with cerebral palsy has arrested social and language development. The nurse tells the family:
- A. This is a sign the cerebral palsy is progressing.'
- B. Your child has reached his maximum language abilities.'
- C. I need to refer you for more developmental testing.'
- D. We need to modify your therapy plan.'
Correct Answer: C
Rationale: Arrested development requires further evaluation to determine the cause and appropriate interventions, so referral for additional testing is necessary.
The nurse reports to the physician signs of increased intracranial pressure in an infant with a myelomeningocele who has which of the following?
- A. A high-pitched cry.
- B. Overflow voiding only.
- C. A fontanel that bulges with crying.
Correct Answer: A
Rationale: A high-pitched cry is a classic sign of increased intracranial pressure in infants, indicating neurological distress. Overflow voiding and a fontanel bulging only with crying are less specific.