Nokea
The nurse is caring for a child with leukemia who reports mouth sores. Which intervention should the nurse implement?
- A. Encourage spicy foods to stimulate appetite.
- B. Provide a soft toothbrush and mild mouth rinse.
- C. Administer aspirin for pain relief.
- D. Avoid oral care until sores heal.
Correct Answer: B
Rationale: A soft toothbrush and mild mouth rinse prevent irritation and infection in mouth sores, common in leukemia due to chemotherapy. Aspirin and spicy foods worsen sores.
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The physician orders a urinalysis for a child who has undergone surgical repair of a hypospadias. Which of the following results should the nurse report to the physician?
- A. Urine specific gravity of 1.017.
- B. Ten red blood cells per high-powered field.
- C. Twenty-five white blood cells per high-powered field.
- D. Urine pH of 6.0.
Correct Answer: C
Rationale: High WBC count indicates infection.
Eight hours ago, an infant with Hirschsprung's disease had surgery to create a colostomy. Which of the following findings should alert the nurse to notify the physician immediately?
- A. A 3-cm increase in abdominal circumference.
- B. Periods of occasional fussiness.
- C. Absence of bowel sounds since surgery.
- D. Evidence of the infant's returning appetite.
Correct Answer: A
Rationale: A 3-cm increase in abdominal circumference may indicate complications like obstruction or bleeding.
A transfusion of packed red blood cells has been ordered for a 1-year-old with sickle cell anemia. The infant has a 25 gauge I.V. infusing dextrose with sodium and potassium. Using the Situation, Background, Assessment, Recommendation (SBAR) method of communication, the nurse contacts the physician and recommends:
- A. Starting a second I.V. with a 22 gauge catheter to infuse normal saline with the blood.
- B. Using the existing I.V., but changing the fluids to normal saline for the transfusion.
- C. Replacing the I.V. with a 22 gauge catheter to infuse the ordered fluids.
- D. Starting a second I.V. with a 25 gauge catheter to infuse normal saline with the transfusion.
Correct Answer: A
Rationale: A second I.V. with a larger 22-gauge catheter ensures safe blood transfusion, as dextrose is incompatible and a 25-gauge is too small.
An 8-year-old child with asthma states, 'I want to play some sports like my friends. What can I do?' The nurse responds to the child based on the understanding of which of the following?
- A. Physical activities are inappropriate for children with asthma.
- B. Children with asthma must be excluded from team sports.
- C. Vigorous physical exercise frequently precipitates an asthmatic episode.
- D. Most children with asthma can participate in sports if the asthma is controlled.
Correct Answer: D
Rationale: Most children with asthma can participate in sports if their condition is well-controlled with appropriate medications and trigger management, allowing them to engage in physical activities safely.
A 10-year-old with scoliosis has to wear a brace. The nurse should develop a teaching plan with the client to include which of the following instructions?
- A. Wear the brace during waking hours.
- B. Wear the brace only during sleep.
- C. Wear a form-fitting, sleeveless T-shirt under the brace.
- D. Bathe the skin under the brace once per week.
Correct Answer: A,C
Rationale: The brace should be worn during waking hours for maximum effectiveness, and a form-fitting T-shirt helps protect the skin and improve comfort.