Nokea
The nurse should plan to keep which equipment or supplies in the burned child's room in case an emergency arises?
- A. An extra supply of sterile dressing
- B. An endotracheal tube and oxygen supply
- C. Equipment to administer pain medication
- D. Additional bags of I.V. fluid
Correct Answer: B
Rationale: Burn patients are at risk for airway compromise due to inhalation injury or edema. Keeping an endotracheal tube and oxygen supply available is critical for emergency airway management.
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The postpartum client (G2P2) asks the nurse for suggestions to help facilitate her 3-year-old’s attachment and acceptance of their newborn. Which action should the nurse suggest?
- A. Provide a doll for the 3-year-old to care for and nurture.
- B. Avoid bringing the 3-year-old to the “scary” hospital.
- C. Plan that dad cares for the 3-year-old and mom cares for the baby.
- D. Encourage the child to be “grown up” and accept the newborn.
Correct Answer: A
Rationale: Providing a doll encourages the 3-year-old to mimic parental care reducing jealousy. Hospital visits shared parental attention and accepting regression promote bonding.
If the child develops shortness of breath when ambulating to the bathroom in the hospital, which intervention should the nurse add to the care plan?
- A. Have the child use a bedside commode for elimination.
- B. Administer oxygen after the child uses the bathroom.
- C. Instruct the child to call for assistance when ambulating to the bathroom.
- D. Provide a walker for the child to use when ambulating to the bathroom.
Correct Answer: A
Rationale: Shortness of breath during ambulation may indicate carditis, a serious complication of rheumatic fever. Using a bedside commode minimizes physical exertion, reducing cardiac workload and the risk of worsening symptoms.
The nurse meets the frantic father at an ED door. He says he just delivered his wife’s full-term newborn in the car when the temperature outside is only 10°F (—12.2°C). In response to the cold environment,the nurse knows that the infant’s body will immediately begin to produce heat by which mechanism?
- A. Shivering
- B. Metabolizing body fat
- C. Dilating surface blood vessels
- D. Decreasing flexion of the extremities
Correct Answer: B
Rationale: When skin receptors of full-term newborns perceive a drop in environmental temperature the sympathetic nervous system is stimulated. This in turn stimulates metabolism of brown fat thus producing heat that is transferred to the peripheral circulation. Shivering is rarely seen in newborns and it does little to produce heat. Newborns conserve heat by constricting not dilating blood vessels. Decreasing flexion promotes heat loss by exposing more skin surface.
How should the nurse position a child who is about to undergo a lumbar puncture?
- A. Prone position
- B. Fowler's position
- C. Supine position
- D. Side-lying position
Correct Answer: D
Rationale: The side-lying position with the back curved and knees flexed maximizes spinal flexion, facilitating access to the subarachnoid space for a lumbar puncture.
The nurse informs the client that acquired immunodeficiency syndrome (AIDS) is commonly associated with which symptoms?
- A. Increased appetite and chills during the night
- B. Tachycardia, dyspnea, and constipation
- C. Fatigue, fever, and persistent yeast infections
- D. Weight gain, peripheral edema, and jaundice
Correct Answer: C
Rationale: AIDS is associated with fatigue, fever, and persistent infections like yeast infections due to immune suppression, making these symptoms characteristic.