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The parents of a 3-year-old suspect that the child has recently ingested a large amount of acetaminophen. The child does not appear in immediate distress. The nurse should anticipate doing which of these interventions in order of priority, from first to last?
- A. Draw acetaminophen serum levels.
- B. Attempt to determine the exact time and amount of drug ingested.
- C. Administer acetylcysteine (Acetadote IV).
- D. Administer activated charcoal.
Correct Answer: B,D,A,C
Rationale: First, determine ingestion details (B) to assess risk. Administer charcoal (D) within 1-2 hours to reduce absorption. Draw serum levels (A) at 4 hours to confirm toxicity. Administer acetylcysteine (C) if levels are toxic.
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Which sign should lead the nurse to suspect that a child with meningitis has developed disseminated intravascular coagulation?
- A. Hemorrhagic skin rash.
- B. Edema.
- C. Cyanosis.
- D. Dyspnea on exertion.
Correct Answer: A
Rationale: A hemorrhagic rash, such as petechiae or purpura, is a hallmark of disseminated intravascular coagulation in meningitis, indicating clotting abnormalities.
The nurse is assessing a 9-year-old child who has third-degree burns as shown below. Using the 'Rule of Nines' adapted for children, the nurse estimates that the extent of burns for this child is:
- A. 9%.
- B. 14%.
- C. 18%.
- D. 24%.
Correct Answer: C
Rationale: In children, the Rule of Nines assigns 18% to each arm (including forearm and hand). A third-degree burn on one forearm approximates 18%, assuming the burn covers the entire forearm as implied.
Anticipating that a 3-year-old child in traction will have need for diversion, what should the nurse offer the child?
- A. I know game.
- B. Blocks.
- C. Hand puppets.
- D. Marbles.
Correct Answer: C
Rationale: Hand puppets are an engaging, age-appropriate diversion for a 3-year-old, promoting interaction without requiring mobility.
Which complication is the nurse most concerned about in an obese child?
- A. Asthma.
- B. Type 2 diabetes.
- C. Seasonal allergies.
- D. Iron deficiency.
Correct Answer: B
Rationale: Obesity increases the risk of type 2 diabetes due to insulin resistance. Asthma and allergies may occur, but diabetes is a more significant concern. Iron deficiency is unrelated.
Discharge teaching for a 3-month-old infant with a cardiac defect who is to receive digoxin (Lanoxin) should include which of the following?
- A. Give the medication at regular intervals.
- B. Mix the medication with a small volume of breast milk or formula.
- C. Repeat the dose one time if the child vomits immediately after administration.
- D. Notify the primary care provider of poor feeding or vomiting.
- E. Make up any missed doses as soon as realized.
- F. Notify the primary care provider if more than 2 consecutive doses are missed.
- G. Keep medication in a safe place, preferably a locked cabinet.
Correct Answer: A,C,D,F,G
Rationale: Digoxin requires regular dosing, safe storage, and monitoring for side effects like vomiting or poor feeding. Vomiting doses should not be repeated due to toxicity risks, and missed doses should not be made up.