Nokea
The nurse is caring for a child with osteomyelitis who will be receiving high-dose intravenous antibiotic therapy for 3 to 4 weeks. What should the nurse plan to monitor?
- A. Blood glucose level.
- B. Thrombin times.
- C. Urine glucose level.
- D. Urine specific gravity.
Correct Answer: D
Rationale: Urine specific gravity should be monitored to assess hydration status, as prolonged antibiotic therapy can affect renal function.
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Shortly after an infant is returned to his room following hydrocele repair, the infant's mother tells the nurse that the child's scrotum looks swollen and bruised. Which of the following responses by the nurse would be most appropriate?
- A. Let me see if the doctor has ordered aspirin for him. If he did
- B. I'll get it right away.
- C. Why don't you wait in his room? Then you can ask me any questions when I get there.
- D. What you are describing is unusual after this type of surgery. I'll let the doctor know.
- E. This is normal after this type of surgery. Let's look at it together just to be sure.
Correct Answer: D
Rationale: Swelling and bruising post-surgery are common.
Which of the following should the nurse include when teaching the father of an infant just admitted with gastroenteritis about initial treatment for his infant?
- A. The infant will receive no liquids by mouth.
- B. Intravenous antibiotics will be started.
- C. The infant will be placed in a mist tent.
- D. An iron-fortified formula will be used.
Correct Answer: A
Rationale: NPO status is common initially to rest the gut during rehydration.
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.
After insertion of bilateral tympanostomy tubes in a toddler, which of the following instructions should the nurse include in the child's discharge plan for the parents?
- A. Insert ear plugs into the canals when the child bathes.
- B. Blow the nose forcibly during a cold.
- C. Administer the prescribed antibiotic while the tubes are in place.
- D. Disregard any drainage from the ear after 1 week.
Correct Answer: C
Rationale: Administering prescribed antibiotics as directed is crucial to prevent infection after tympanostomy tube insertion. Ear plugs are not typically recommended, as they can introduce bacteria. Forcibly blowing the nose can disrupt the tubes, and any drainage after 1 week should be reported, not disregarded.
The nurse identifies a nursing diagnosis of Risk for perioperative-positioning injury related to the surgical procedure for a school-age child scheduled for a tonsillectomy. Which of the following is an expected outcome for this nursing diagnosis?
- A. The child is able to tell about the surgery and recovery.
- B. The child remains on nothing-by-mouth (NPO) status for the designated preoperative period.
- C. The child and family demonstrate an understanding of the procedure.
- D. The child knows the parents will not leave.
Correct Answer: B
Rationale: The most appropriate outcome for a nursing diagnosis of Risk for perioperative-positioning injury related to the surgical procedure should be that the child remains NPO for the designated period of time before surgery, thereby minimizing the risk of aspiration during the surgery. Ability to tell about the surgery and demonstrating an understanding of the procedure are appropriate outcomes for a nursing diagnosis of Deficient knowledge. Knowing that the parents will not leave is associated with a nursing diagnosis of Anxiety or Fear related to separation from support systems or an unfamiliar environment.