Nokea
The nurse is transferring a child who has had open heart surgery from the pediatric intensive care unit to the pediatric unit. The child's blood pressure has been fluctuating but has been stable during the last 2 hours. The nurse from the pediatric intensive care unit should include which of the following information in the report to the nurse on the pediatric unit?
- A. Medications being used.
- B. Current vital signs.
- C. Potential for blood pressure to drop.
- D. Drip rate for the intravenous infusion.
- E. Time of the most recent dose of pain medication.
Correct Answer: A,B,C,D,E
Rationale: All listed information is critical for continuity of care, ensuring the receiving nurse can monitor and manage the child's condition effectively.
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When caring for an infant post-repair of an anorectal malformation, which of the following should the nurse monitor to prevent complications?
- A. Skin integrity around the surgical site.
- B. Frequency of oral feedings.
- C. Daily weight gain.
- D. Parental bonding behaviors.
Correct Answer: A
Rationale: Monitoring skin integrity prevents infection and breakdown at the surgical site.
The parents of a child tell the nurse that they feel guilty because their child almost drowned. Which of the following remarks by the nurse would be most appropriate?
- A. I can understand why you feel guilty, but these things happen.'
- B. Tell me a little bit more about your feelings of guilt.'
- C. You should not have taken your eyes off of your child.'
- D. You really shouldn't feel guilty; you're lucky because your child will be all right.'
Correct Answer: B
Rationale: Encouraging parents to express their feelings facilitates therapeutic communication and supports emotional processing.
During physical assessment of a 4-month-old infant with Hirschsprung's disease, the nurse should most likely note which of the following?
- A. Scaphoid-shaped abdomen.
- B. Weight less than expected for height and age.
- C. Cyanosis of the fingers and toes.
- D. Hyperactive deep tendon reflexes.
Correct Answer: B
Rationale: Hirschsprung's disease can lead to poor weight gain due to bowel obstruction.
When taking a diet history from the mother of a 7-year-old child with phenylketonuria, a report of which of the following foods indicates a need for further teaching?
- A. Low-protein bread.
- B. Special PKU formula.
- C. Fresh apples.
- D. Chicken nuggets.
Correct Answer: D
Rationale: Chicken nuggets are high in phenylalanine, contraindicated in PKU. Low-protein bread, PKU formula, and apples are appropriate for a PKU diet.
The nurse should instruct the family of a child with newly diagnosed hyperthyroidism to:
- A. Keep their home warmer than usual.
- B. Encourage twenty or outdoor activities.
- C. Promote interactions with one friend instead of groups.
- D. Limit bathing to prevent skin irritation.
Correct Answer: C
Rationale: Hyperthyroidism causes irritability and hyperactivity, so limiting social interactions to one friend reduces overstimulation. Warmer homes, excessive activity, and limited bathing are inappropriate.