Nokea
The nurse is preparing to complete documentation on a patient's chart. Which should be included in documentation of nursing care? (Select all that apply.)
- A. Reassessments
- B. Nursing care provided
- C. Initial assessments
- D. All of the above
Correct Answer: D
Rationale: Proper documentation includes reassessments, initial assessments, care provided, and the patient's response, but incident reports are typically documented separately.
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The nurse is using a bulb syringe to suction a neonate after delivery. What is an important consideration?
- A. Compress the bulb before insertion.
- B. Clear the mouth and pharynx before the nasal passages.
- C. Use two bulb syringes, one for the mouth and pharynx and one for the nasal passages.
- D. Continue using a bulb syringe until secretions are removed as mechanical suction is contraindicated.
Correct Answer: B
Rationale: The correct consideration when using a bulb syringe to suction a neonate after delivery is to clear the mouth and pharynx before the nasal passages to prevent aspiration of amniotic fluid. Compressing the bulb syringe before insertion is important to create suction. Using two bulb syringes is unnecessary, as one is sufficient for both the mouth/pharynx and nasal passages. It is not recommended to continue using a bulb syringe until all secretions are removed; instead, mechanical suction can be employed if more forceful removal of secretions is required.
Which responsibilities are included in the pediatric nurse's promotion of the health and well-being of children? (Select all that apply.)
- A. Promoting disease prevention
- B. Providing financial assistance
- C. Providing support and counseling
- D. A, C
Correct Answer: D
Rationale: Pediatric nurses promote health through disease prevention, support, counseling, therapeutic relationships, and participating in ethical decision-making.
Why does the nurse have a 2-year-old boy sit in a "tailor" position while palpating for the presence of the testes?
- A. It prevents the cremasteric reflex
- B. Undescended testes can be palpated
- C. The child has an inguinal hernia
- D. The child does not yet have a need for privacy
Correct Answer: A
Rationale: The tailor position stretches the muscle responsible for the cremasteric reflex, preventing it from contracting and pulling the testes into the pelvic cavity. This position helps accurately palpate the testes. Choice B is incorrect because the position does not facilitate the palpation of undescended testes specifically. Choice C is incorrect as it does not relate to the rationale behind the tailor position. Choice D is incorrect as the reason for using the tailor position is not related to the child's need for privacy.
The charge nurse in the pediatric unit is teaching nursing students about pyloric stenosis. A student asks what causes pyloric stenosis. How should the nurse respond?
- A. One portion of the intestines invaginates or telescopes into another
- B. Hypertrophy of the circular pylorus muscle
- C. Relaxed cardiac sphincter
- D. Absent ganglion cells in the colon
Correct Answer: B
Rationale: Pyloric stenosis is caused by the hypertrophy (thickening) of the circular muscle of the pylorus, leading to obstruction. Choice A is incorrect as it describes intussusception, not pyloric stenosis. Choice C is incorrect as a relaxed cardiac sphincter is related to gastroesophageal reflux. Choice D is incorrect as it describes Hirschsprung's disease, not pyloric stenosis.
The nurse is caring for an adolescent hospitalized for asthma. The adolescent belongs to a large family. The nurse recognizes that the adolescent is likely to relate to which group?
- A. Peers
- B. Parents
- C. Siblings
- D. Teachers
Correct Answer: A
Rationale: Adolescents typically identify and relate more closely to their peer group, especially during the teenage years when peer relationships become a central focus.