Nokea
The nurse is planning care for the adolescent. Select the 5 interventions the nurse should include.
- A. Instruct the parent to ensure the pneumococcal vaccine is current.
- B. Administer folic acid as prescribed.
- C. Monitor oxygen saturation continuously.
- D. Place the client on strict bed rest.
- E. Apply cold compresses to the affected joints.
- F. Administer meperidine IV for pain.
Correct Answer: B,C,E,F,H
Rationale: The correct interventions for the adolescent are B, C, E, F, and H. Administering folic acid (B) is important for growth and development. Monitoring oxygen saturation (C) ensures respiratory function. Applying cold compresses (E) helps reduce inflammation in affected joints. Administering meperidine IV (F) addresses pain management. The rationale for excluding other choices: A is irrelevant for adolescent care, D may worsen joint symptoms, and G is incomplete.
You may also like to solve these questions
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.
Which of the following information should the nurse include in the teaching?
- A. Place an infant who is 5 months old in a high chair to feed.
- B. Position a 1-month-old infant supine on a soft mattress.
- C. Provide an infant with a one-piece pacifier for non-nutritive sucking.
- D. Secure the infant's car seat behind an airbag.
Correct Answer: C
Rationale: The correct answer is C because providing an infant with a one-piece pacifier for non-nutritive sucking reduces the risk of choking and aspiration compared to multi-piece pacifiers. This information is crucial for infant safety during feeding. Choice A is incorrect as a 5-month-old infant should be seated in a high chair only if they can sit upright without support to prevent falls. Choice B is incorrect as placing a 1-month-old infant supine on a soft mattress increases the risk of sudden infant death syndrome (SIDS). Choice D is incorrect as securing an infant's car seat behind an airbag can be dangerous due to the risk of injury from the airbag deployment.
Which of the following findings should the nurse expect?
- A. Cyanosis
- B. Weight loss
- C. Bounding peripheral pulses
- D. Dyspnea
- E. Tachycardia
Correct Answer: A,D,E
Rationale: The correct answer is A, D, and E. Cyanosis indicates poor oxygenation, dyspnea signifies difficulty in breathing, and tachycardia suggests an increased heart rate to compensate for decreased oxygen levels. Weight loss and bounding peripheral pulses are not typical findings in a patient with impaired oxygenation. In summary, the nurse should expect cyanosis, dyspnea, and tachycardia as key findings in a patient with compromised oxygenation.
The child's parents ask for information on hemodialysis. Which of the following statements should the nurse make?
- A. Hemodialysis uses your child's abdominal cavity as a membrane to clean their blood.
- B. Hemodialysis uses an electrolyte solution to clean your child's blood.
- C. Hemodialysis uses an artificial membrane outside the body to clean your child's blood.
- D. Hemodialysis slowly filtrates your child's blood continuously.
Correct Answer: C
Rationale: The correct answer is C. Hemodialysis uses an artificial membrane outside the body to clean the child's blood. This is because hemodialysis involves the process of blood being filtered through a machine that uses a synthetic membrane to remove wastes and excess fluids. This process mimics the function of the kidneys in filtering the blood.
Choice A is incorrect because hemodialysis does not use the abdominal cavity as a membrane, it uses an external artificial membrane. Choice B is incorrect as hemodialysis does not involve the use of an electrolyte solution to clean the blood. Choice D is incorrect because hemodialysis is not a continuous filtration process, it is done intermittently during treatment sessions.
Which of the following findings should the nurse report to the provider?
- A. Drainage from the chest tube of 22 mL in the last hour
- B. Urine output of 15 mL in the last 2 hr
- C. Skin temperature 36° C (96.8° F)
- D. Pedal and posterior tibial pulses of 2+
Correct Answer: B
Rationale: The correct answer is B: Urine output of 15 mL in the last 2 hr. Inadequate urine output can indicate renal impairment or inadequate fluid intake. This is a critical finding that needs immediate attention to prevent further complications like acute kidney injury. A: Drainage from the chest tube of 22 mL in the last hour is within the normal range. C: Skin temperature of 36°C (96.8°F) is within normal limits. D: Pedal and posterior tibial pulses of 2+ indicate normal circulation.