Nokea
The nurse is teaching a school-age child with left femoral osteomyelitis and the child's parent before discharge. What instruction should the nurse give related to the initial phase of treatment?
- A. Ensure no weight bearing on the affected extremity
- B. Administer topical antibiotic therapy daily
- C. Schedule ice pack applications to the infected area
- D. Provide passive range of motion exercises
Correct Answer: A
Rationale: No weight bearing prevents further bone damage during the initial treatment phase of osteomyelitis, supporting infection control.
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A mother brings her 3-month-old infant to the clinic because the baby does not sleep through the night. Which finding is most significant in planning care for this family?
- A. The diaper area shows severe skin breakdown
- B. The mother states the baby is irritable during feedings
- C. The mother is a single parent and lives with her parents
- D. The infant's formula has been changed twice
Correct Answer: A
Rationale: Severe diaper dermatitis causes discomfort, impacting sleep and requiring immediate care.
During a routine clinic visit, a nurse finds that a 5-year-old girl's systolic blood pressure is above the 90th percentile. What should be the nurse's subsequent action?
- A. Refer the child to the healthcare provider and schedule a blood pressure evaluation in two weeks.
- B. Perform a comprehensive assessment and avoid repeated blood pressure measurements during the examination.
- C. Take the child's blood pressure three times during the visit and record the highest reading.
- D. Measure the blood pressure twice more during the visit and calculate the average of the three readings.
Correct Answer: D
Rationale: Averaging three readings ensures accuracy of elevated blood pressure findings.
A 9-week-old infant is scheduled for a cleft lip repair. What information is most important for the nurse to convey to the surgeon before transporting the infant to the surgical suite?
- A. Urine specific gravity is 1.011
- B. White blood cell count of 10,000/mm³
- C. Weight gain of 2 pounds (0.91 kg) since birth
- D. Red blood cell count of 2.3 x 10²/L
Correct Answer: D
Rationale: A low red blood cell count indicates anemia, a surgical risk requiring preoperative attention.
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.
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.