Nokea
The nurse is preparing to administer medications for an eight-month-old infant with heart failure. The infant has a blood pressure of 114/66 mm Hg, apical pulse of 88 beats/minute, and respirations of 30 breaths/minute. Which medication should the nurse withhold until the healthcare provider is notified?
- A. Digoxin.
- B. Furosemide.
- C. Hydralazine.
- D. Enalapril.
Correct Answer: A
Rationale: Digoxin should be withheld if the apical pulse is below 90 beats/minute in infants, as it may indicate toxicity.
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When starting a peripheral intravenous (IV) infusion on an infant, which intervention should the nurse implement?
- A. Select a site that is least restrictive to the infant.
- B. Assess dorsal surface of feet for an IV site.
- C. Instruct parents to sing or croon to the infant.
- D. Apply soft restraints to all four extremities.
Correct Answer: A
Rationale: Selecting a least restrictive site minimizes discomfort and maintains mobility, ensuring safe and effective IV placement.
A child who weighs 18 pounds receives a prescription for amoxicillin 25 mg/kg/day by mouth in divided doses every 12 hours. The bottle is labelled, 'Amoxicillin for Oral Suspension, USP 400 mg per 5 mL.' How many mL should the nurse administer with each dose?
- A. 1.3 mL
Correct Answer: A
Rationale: The dose is calculated as 18 lbs ÷ 2.2 = 8.18 kg, 25 mg/kg/day x 8.18 kg = 204.5 mg/day, divided into 102.25 mg/dose. Then, 102.25 mg ÷ (400 mg/5 mL) = 1.3 mL.
A 9-week-old infant is scheduled for a cleft lip repair. Which information is most important for the nurse to convey to the surgeon before transporting the infant to the surgical suite?
- A. White blood cell count of 10,000/mm (10x 10/L).
- B. Weight gain of 2 pounds (0.91 kg) since birth.
- C. Red blood cell count of 2.3 cell/mcl or (2.3 x 10/L).
- D. Urine specific gravity is 1.011.
Correct Answer: C
Rationale: A low red blood cell count indicates anemia, increasing surgical risks, making it critical to report to the surgeon.
When developing a teaching plan for an adolescent male who was recently diagnosed with Type 1 diabetes mellitus, the nurse should instruct the client to eat a source of sugar if which symptom occurs?
- A. Racing pulse.
- B. Profuse perspiration.
- C. Excessive thirst.
- D. Seeing spots.
Correct Answer: B
Rationale: Profuse perspiration is a symptom of hypoglycemia, requiring immediate sugar intake to raise blood glucose levels.
The nurse is assessing the growth and development of a 3-year-old child. Which speech and language skills should the nurse identify as normal developmental milestones for this child?
- A. Speaks in simple sentences with four or more words.
- B. Recognizes most letters and numbers.
- C. Uses gestures with 1-to-2-word sentences.
- D. Uses 1-word sentences.
Correct Answer: A
Rationale: Speaking in simple sentences with four or more words is a normal milestone for a 3-year-old.