Nokea
The nurse is caring for an infant with a temporary colostomy due to Hirschsprung's disease. Which of the following indicates proper stoma care?
- A. Cleaning the stoma with alcohol.
- B. Keeping the stoma dry and exposed.
- C. Applying a barrier cream around the stoma.
- D. Covering the stoma with a sterile dressing.
Correct Answer: C
Rationale: A barrier cream protects the skin around the stoma from irritation.
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A 9-month-old child with cystic fibrosis does not like to take a pancreatic enzyme supplement with meals and snacks. The mother does not like to force the child to take the supplement. The most important reason for the child to take the pancreatic enzyme supplement with meals and snacks is:
- A. The child will become dehydrated if the supplement is not taken with meals and snacks.
- B. The child needs these pancreatic enzymes to help the digestive system absorb fats, carbohydrates, and proteins.
- C. The child needs the pancreatic enzymes to aid in liquefying mucus to keep the lungs clear.
- D. The child will experience severe diarrhea if the supplement is not taken as prescribed.
Correct Answer: B
Rationale: Pancreatic enzyme supplements are essential in cystic fibrosis to aid digestion and absorption of fats, carbohydrates, and proteins, compensating for pancreatic insufficiency.
An adolescent with a history of losing weight and fatigue is admitted to the hospital with a diagnosis of stage I chronic renal failure. Based on these fi ndings, the nurse should:The chart shows:
- A. Continue monitoring intake and output.
- B. Notify the physician.
- C. Restrict the client’s fluids.
- D. Increase the client’s fluids.
Correct Answer: B
Rationale: The nurse would expect a person with a normal GFR to have approximately equal inputs and outputs. Chronic renal failure has fi ve stages. In stage I the glomerular fi ltration rate (GFR) is approximately ≥90 mL/minute/1.73 m2. In stage II the GFR decreases to approximately 60 to 89 mL/minute/1.73 m2. The decreased urine output may indicate worsening disease and should be reported. Assessing the client’s intake and output is still important, but notifying the provider is the priority. Fluids are restricted based on decreased sodium. Clients are encouraged to drink to thirst. Therefore, there is not enough information to suggest increasing or restricting fl uids.
Which of the following diet plans would be appropriate for the nurse to discuss with the family of a child with acute renal failure?
- A. High carbohydrate and protein.
- B. High fat and carbohydrate.
- C. Low fat and protein.
- D. Low in carbohydrate and fat.
Correct Answer: A
Rationale: High carb/protein supports nutritional needs.
A 16-month-old child is seen in the clinic for a checkup for the first time. The nurse notices that the toddler limps when walking. Which of the following would be appropriate to use when assessing this toddler for developmental dysplasia of the hip?
- A. I couldn'ts maneuver.
- B. Barlow's maneuver.
- C. Adam's position.
- D. Trendelenburg's sign.
Correct Answer: B
Rationale: Barlow's maneuver is used to assess for hip instability in infants and toddlers, appropriate for detecting developmental dysplasia of the hip.
A child with Kawasaki disease is receiving low dose aspirin. The mother calls the clinic and states that the child has been exposed to influenza. Which recommendations should the nurse make?
- A. Increase fluid intake.
- B. Stop the aspirin.
- C. Keep the child home from school.
- D. Watch for fever.
- E. Weigh the child daily.
Correct Answer: B,C,D
Rationale: Aspirin should be stopped due to the risk of Reye's syndrome with influenza. Keeping the child home and monitoring for fever help manage infection risk.