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The nurse is caring for an adolescent with type 1 diabetes mellitus who presents with an HbA1c of 11% (97 mmol/mol), thirst, and blurred vision. What action should the nurse take first?
- A. Obtain point-of-care glucose.
- B. Assess urine for ketones.
- C. Check blood pressure.
- D. Review prior insulin prescriptions.
Correct Answer: A
Rationale: Symptoms suggest hyperglycemia; point-of-care glucose testing confirms this and guides treatment.
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A newborn with a repaired gastroschisis is transferred to the pediatric unit after several days in the pediatric intensive care unit. The infant is receiving parenteral nutrition and continuous enteral feedings. To maintain normal growth and development of the infant, which action should the nurse include in the plan of care?
- A. Speak to the healthcare provider about instituting physical therapy.
- B. Offer a pacifier for non-nutritive sucking.
- C. Ensure placement of the enteral tube with an abdominal x-ray.
- D. Use sterile technique during feedings.
Correct Answer: B
Rationale: Offering a pacifier for non-nutritive sucking promotes oral feeding skills and emotional stability, supporting normal growth and development in infants with gastroschisis repair.
The nurse begins collecting the medical history of a child when the child screams and tries to hide behind the parent, dropping a stuffed toy. What intervention should the nurse implement?
- A. Obtain the essential information as quickly as possible.
- B. Include the child's toy in the collection of information.
- C. Document interactions between the parent and the child.
- D. Ignore the child's behavior, directing Questions to a parent.
Correct Answer: B
Rationale: Using the toy reduces fear, creating a comfortable environment for history collection.
A 5-week-old infant who has been experiencing projectile vomiting after feedings. What additional symptom should the nurse anticipate?
- A. Stool containing mucus and blood.
- B. An olive-sized mass in the epigastric region.
- C. Frequent burping accompanied by poor feeding.
- D. Rebound tenderness in the left lower abdominal quadrant.
Correct Answer: B
Rationale: An olive-sized mass suggests pyloric stenosis, a common cause of projectile vomiting.
When initiating a peripheral intravenous (IV) infusion on an infant, what action should the nurse take?
- A. Apply soft restraints to all four extremities.
- B. Assess the dorsal surface of the feet for an IV site.
- C. Instruct parents to sing or croon to the infant.
- D. Select a site that is least restrictive to the infant.
Correct Answer: D
Rationale: Choosing a least restrictive site minimizes distress and allows easier movement post-IV insertion.
The parents of a child who is diagnosed with Wilm's tumor ask the nurse why surgery is necessary before a biopsy is performed. What information should the nurse provide?
- A. The surgery provides a visualization of other pathology and dysfunction of the kidney.
- B. Surgery is necessary to stage the tumor and determine metastasis to other sites.
- C. Metal clips are surgically applied at the tumor site for exact marking for radiation.
- D. Biopsy may rupture the encapsulated tumor and cause the cancer cells to spread.
Correct Answer: D
Rationale: Biopsy risks rupturing the tumor, potentially spreading cancer cells.