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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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Which client symptoms documented by the nurse best indicate that the child is having a hypoglycemic reaction? Select all that apply.
- A. The child complains of being thirsty.
- B. The child's breathing is labored and prolonged.
- C. The child is more hungry than usual.
- D. The child complains of feeling shaky.
- E. The child reports feeling light-headed.
- F. The child states his or her heart is racing.
Correct Answer: D,E,F
Rationale: Hypoglycemia causes shakiness, light-headedness, and tachycardia due to low blood glucose triggering the sympathetic nervous system. Thirst and hunger are less specific, and labored breathing is unrelated.
When a 10-year-old child falls from a bicycle and loses a permanent incisor tooth, which advice can the nurse provide to the parents before they take the child to see a dentist?
- A. Submerge the tooth in water in a cup.
- B. Place the tooth under the child's tongue.
- C. Wrap the tooth in a clean cloth.
- D. Clean the tooth with alcohol.
Correct Answer: C
Rationale: Wrapping the tooth in a clean cloth preserves it for potential reimplantation by keeping it clean and protected without compromising its viability.
Which statement by the parents indicates they understand the home care instructions given by the nurse?
- A. We've made arrangements for a homebound teacher.
- B. We'll use ice packs on our child's joints during episodes of inflammation.
- C. We'll serve meals that prevent excess weight gain.
- D. We'll keep our child in bed most of the time.
Correct Answer: C
Rationale: Maintaining a healthy weight reduces stress on inflamed joints in JRA. Serving meals that prevent excess weight gain shows understanding of home care instructions to support joint health.
The nurse is caring for the full-term newborn male who is 24 hours old and was circumcised with a Gomco clamp 30 minutes ago. Which interventions should the nurse plan for care of the newborn’s circumcision? Select all that apply.
- A. Monitor the newborn’s penis hourly for 4 to 6 hours.
- B. Observe for and document the first voiding after circumcision.
- C. Use prepackaged commercial diaper wipes for perineal cleansing.
- D. Apply petroleum ointment around the penis after each diaper change.
- E. Apply tightly a size-smaller diaper to provide hemostasis.
Correct Answer: A,B,D
Rationale: Monitor the penis for swelling/bleeding document first void to rule out obstruction and apply petroleum ointment to prevent bleeding. Commercial wipes may irritate and tight diapers cause pain.
A 24 years old G3P2 presents to you at 32 weeks of gestation with preterm prelabour rupture of membranes for ten days. She is complaining of pain in lower abdomen,fever with rigors and chills and purulent vaginal discharge. What is her diagnosis:
- A. Pyrexia of unknown origin.
- B. Puerperal pyrexia.
- C. Preterm labour.
- D. Chorioamnionitis.
- E. Antepartum haemorrhage.
Correct Answer: D
Rationale: Chorioamnionitis is an infection of the amniotic membranes often following prolonged rupture of membranes presenting with fever abdominal pain and purulent discharge. Other options do not fit the clinical picture.