Nokea
Which of the following statements should the nurse include?
- A. Notify the provider if your child has dark brown blood between their teeth.
- B. Encourage your child to drink liquids through a straw.
- C. Notify the provider if your child is swallowing frequently.
- D. Encourage your child to clear their throat as needed.
Correct Answer: C
Rationale: The correct answer is C, "Notify the provider if your child is swallowing frequently." This statement is important as frequent swallowing may indicate potential issues such as aspiration or difficulty swallowing. It is crucial for the nurse to be aware of this symptom to ensure timely intervention.
Choice A is incorrect because dark brown blood between the teeth is not a typical symptom that would require immediate notification to the provider. Choice B is also incorrect as encouraging a child to drink through a straw may not be relevant to the situation at hand. Choice D is incorrect as clearing the throat as needed may not address the underlying issue of frequent swallowing.
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Which of the following actions should the nurse take first?
- A. Check the pH of the gastric secretions.
- B. Set the administration rate on the feeding pump.
- C. Flush the tube with water.
- D. Attach the feeding bag tubing to the end of the NG tube.
Correct Answer: C
Rationale: The nurse should first flush the tube with water to ensure patency and prevent clogging. This step clears any residual medication or debris, allowing for safe and effective administration of feedings. Checking the pH of gastric secretions (A) is important but can be done after ensuring tube patency. Setting the administration rate (B) and attaching the feeding bag tubing (D) are premature without confirming tube patency. The correct order prioritizes patient safety and optimal feeding delivery.
Specify what condition the client is most likely experiencing.
- A. Pyloric stenosis
- C. Congestive heart failure
- D. Respiratory syncytial virus bronchiolitis
Correct Answer: C
Rationale: The correct answer is C: Congestive heart failure. The client is most likely experiencing Congestive heart failure due to presenting symptoms such as dyspnea, fatigue, edema, and possibly crackles on lung auscultation. These symptoms are indicative of fluid accumulation in the lungs and peripheral tissues, common in congestive heart failure. Pyloric stenosis (A) is a gastrointestinal condition, not related to the symptoms described. Respiratory syncytial virus bronchiolitis (D) typically presents with respiratory distress in infants. The other choices are omitted as they are not relevant to the symptoms described.
For which of the following adverse effects should the nurse monitor?
- A. Hypotension
- B. Prolonged wound healing
- C. Stevens-Johnson syndrome
- D. Bradypnea
Correct Answer: C
Rationale: The correct answer is C: Stevens-Johnson syndrome. This is a severe adverse reaction characterized by blistering and peeling of the skin, mucous membranes involvement, and flu-like symptoms. It is potentially life-threatening and requires immediate medical intervention. The nurse should monitor for early signs such as rash, fever, and mucosal lesions. Choices A, B, and D are not typically associated with the medication's adverse effects. Hypotension is a common side effect of some medications but not the focus of monitoring for this specific drug. Prolonged wound healing is more related to factors like nutrition and comorbidities. Bradypnea (slow breathing) is not commonly associated with adverse effects of medications but could signify respiratory distress.
The nurse should monitor the child for which of the following complications?
- A. Nuchal rigidity when standing
- B. Double vision
- C. Headache
- D. Pain in the posterior iliac crest
Correct Answer: C
Rationale: The correct answer is C: Headache. In pediatric patients, headaches can be indicative of serious underlying conditions such as meningitis or increased intracranial pressure. Monitoring for headaches is crucial for early detection and intervention. Nuchal rigidity when standing (A) is more indicative of meningitis in adults. Double vision (B) is more associated with neurological issues. Pain in the posterior iliac crest (D) is not typically a complication that requires monitoring in children.
The nurse should teach the parents to take which of the following actions during a seizure?
- A. Minimize movement of the limbs.
- B. Clear the area of hard objects.
- C. Place the child in a prone position.
- D. Insert a tongue blade between the teeth.
Correct Answer: B
Rationale: The correct answer is B: Clear the area of hard objects. This action is crucial during a seizure to prevent injury. Hard objects can cause harm if the child hits them during convulsions. Minimizing limb movement is not recommended as it may lead to further injury. Placing the child in a prone position can obstruct breathing and should be avoided. Inserting a tongue blade can also cause harm and is not recommended. Clearing the area of hard objects is the most effective way to ensure safety during a seizure.