Nokea
The nurse judges that the mother understands the diet restrictions for her child with chronic renal failure who is receiving peritoneal dialysis when she reports providing a diet involving which of the following?
- A. Sodium and water restrictions.
- B. High protein and carbohydrates.
- C. High potassium and iron.
- D. Protein and phosphorus restrictions.
Correct Answer: A
Rationale: Dietary restrictions help manage symptoms.
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When developing the plan of care for a toddler who has taken an acetaminophen overdose, which of the following should the nurse expect to include as part of the initial treatment?
- A. Frequent blood level determinations.
- B. Gastric lavage.
- C. Tracheostomy.
- D. Electrocardiogram.
Correct Answer: A
Rationale: Frequent blood level monitoring guides acetylcysteine therapy. Gastric lavage is less effective than charcoal, and tracheostomy or ECG are not typically needed unless complications arise.
A diagnosis of hemophilia A is confirmed in an infant. Which of the following instructions should the nurse provide the parents as the infant becomes more mobile and starts to crawl?
- A. Administer one-half of a children's aspirin for a temperature higher than 101°F (38.3°C).
- B. Sew thick padding into the elbows and knees of the child's clothing.
- C. Check the color of the child's urine every day.
- D. Expect the eruption of the primary teeth to produce moderate to severe bleeding.
Correct Answer: B
Rationale: Padding protects joints from trauma, reducing bleeding risk in hemophilia. Aspirin increases bleeding, urine checks are unnecessary, and teething bleeding is minimal.
The nurse is caring for a child in Bryant's traction (see figure). The nurse should:
- A. Adjust the weights on the legs until the buttocks rest on the bed.
- B. Provide frequent skin care.
- C. Place a pillow under the buttocks.
- D. Remove the elastic leg wraps every 8 hours for 10 minutes.
Correct Answer: B
Rationale: Frequent skin care is essential in Bryant's traction to prevent pressure ulcers due to prolonged immobility.
When assessing the development of a 15-month-old child with cerebral palsy, which of the following milestones should the nurse expect a toddler of this age to have achieved?
- A. Walking up steps.
- B. Using a spoon.
- C. Copying a circle.
- D. Putting a block in cup.
Correct Answer: D
Rationale: A 15-month-old typically can put a block in a cup, a milestone achievable even with motor challenges from cerebral palsy, unlike the other options which require more advanced skills.
The health care team wishes to establish a policy regarding sleep positions for infants with gastroesophageal reflux (GER). The first step should be to search for:
- A. Policies from other hospitals.
- B. Data from retrospective studies.
- C. Published national standards.
- D. Expert opinions.
Correct Answer: C
Rationale: National standards provide evidence-based guidance for policy development.