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A nurse is reinforcing teaching given to the parent of a 1-year-old child who has had a high temperature, vomiting, and diarrhea for 48 hr. The child has sunken eyes and cracked lips. Which of the following should the nurse tell the parent?
- A. Give the infant applesauce and rice cereal because these have been found to have high nutritional value.
- B. Encourage the child to take sips of chicken or beef broth because they will replace the fluid losses your child is experiencing.
- C. Give the infant oral rehydration solutions that are available commercially. They replace some of the electrolytes lost through vomiting.
- D. Give the child nothing by mouth for 4 hr. Once the vomiting has decreased you can introduce sips of clear water.
Correct Answer: C
Rationale: Oral rehydration solutions effectively replace fluids and electrolytes lost due to vomiting and diarrhea.
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A 16-year-old client reports to the school nurse because of nausea and vomiting. After exploring the signs and symptoms with the client, the nurse asks the girl whether she could be pregnant. The girl confirms that she is pregnant, but states that she does not know how it happened. Which nursing diagnosis is most important?
- A. Altered nutrition: less than body requirements related to nausea and vomiting
- B. Risk for altered family processes related to the client's age
- C. Ineffective individual coping related to denial of pregnancy
- D. Knowledge deficit related to the client's developmental stage and age
Correct Answer: D
Rationale: The correct answer is D: Knowledge deficit related to the client's developmental stage and age. This nursing diagnosis is most important because the client's lack of understanding about how pregnancy occurs indicates a significant gap in knowledge. It is crucial to provide education on sexual health and reproduction to prevent future unplanned pregnancies and promote informed decision-making.
Choice A is incorrect as addressing altered nutrition is important but not the priority in this situation. Choice B is incorrect as the client's age does not necessarily indicate a need for immediate intervention in family processes. Choice C is incorrect as the primary issue is the client's lack of knowledge, not denial of pregnancy.
In summary, choice D is the most important nursing diagnosis as it directly addresses the root cause of the client's situation and has the potential to positively impact her future health and well-being.
The dosage of a pediatric medication is 120mg/kg/day to be given t.i.d. The patient weighs 12 pounds. What is the correct dose for the nurse to administer?
- A. 120 mg
- B. 480 mg
- C. 218 mg
- D. 651 mg
Correct Answer: C
Rationale: The patient weighs twelve pounds, which converts to kilograms by dividing 12 by 2.2 (1 kg = 2.2 lb.). In this example, the child's weight converts to 5.4 kg. The daily dose of 120 mg is given t.i.d: each individual dose is 40 mg/kg. Then multiply the weight in kilograms by the individual dose (40mg). The individual dose is 218 mg.
The nursery nurse reviews a newborn's birth history and notes that the Apgar scores were 5 at one minute after birth, and 7 at five minutes after birth. How should the nurse interpret these scores? The infant:
- A. Needed brief oral and nasal suctioning.
- B. Required endotracheal intubation and bagging with a hand-held resuscitator.
- C. Was stillborn and required CPR.
- D. Required physical stimulation and supplemental oxygen.
Correct Answer: D
Rationale: The correct answer is D: Required physical stimulation and supplemental oxygen. The Apgar score assesses a newborn's overall condition at birth based on five criteria: heart rate, respiratory effort, muscle tone, reflex irritability, and color. A score of 5 at one minute indicates the infant needed assistance, such as stimulation to breathe and oxygen support. The score of 7 at five minutes shows improvement but still requires some intervention. Choices A, B, and C are incorrect because they suggest more aggressive interventions that are not indicated based on the Apgar scores provided, as the infant's condition was not critical enough to warrant those actions.
Which of the following approaches is the most accurate way to measure the heart rate of a 10-month-old infant?
- A. "Apical"'
- B. "Radial"'
- C. "Ulna"'
- D. "Brachial"'
Correct Answer: A
Rationale: The correct answer is A: "Apical." This method involves placing the stethoscope over the apex of the heart to directly listen to the heart sounds. In infants, especially 10-month-olds, the apical pulse is more accurate as it allows for a direct assessment of the heart rate without interference from other factors like peripheral pulses. The apical pulse is easier to locate in infants due to their smaller chest size and thinner chest walls. Choices B, C, and D (Radial, Ulna, and Brachial) are incorrect for measuring heart rate in infants as they involve peripheral pulse sites which may not provide an accurate representation of the heart rate due to various factors like weak pulses or difficulty in palpating them accurately in infants.
A nurse provided discharge teaching to new parents on how to care for their newborn following circumcision. Which of the following statements by the parents indicates the need for further clarification?
- A. I should not remove the yellow exudate on the end of the penis.
- B. I will clean his penis with each diaper change.
- C. The circumcision will heal completely within a couple of weeks.
- D. I can give him a tub bath in two days.
Correct Answer: D
Rationale: The correct answer is D: "I can give him a tub bath in two days." This statement indicates the need for further clarification because newborns who have undergone circumcision should avoid submerging the area in water until it is fully healed to prevent infection. Tub baths should be avoided until the circumcision site has completely healed, which usually takes about 7-10 days. It is important to keep the area clean and dry during this time to promote healing.
Explanation for other choices:
A: "I should not remove the yellow exudate on the end of the penis." - Correct, as it is normal and part of the healing process.
B: "I will clean his penis with each diaper change." - Correct, as keeping the area clean helps prevent infection.
C: "The circumcision will heal completely within a couple of weeks." - Correct, as the healing process typically takes around 1-2 weeks.