Nokea
The practical nurse is caring for a child who has just returned from surgery for an appendectomy. Which intervention should the nurse implement?
- A. Encourage early ambulation.
- B. Apply warm compresses to the incision site.
- C. Monitor for signs of infection at the surgical site.
- D. Provide a high-fiber diet immediately post-op.
Correct Answer: C
Rationale: Monitoring for signs of infection at the surgical site is crucial after an appendectomy as it helps in early detection and treatment of any potential complications. This intervention is essential for ensuring the child's proper healing and recovery post-surgery. Encouraging early ambulation is generally beneficial post-operatively but may not be the priority immediately after an appendectomy. Applying warm compresses to the incision site may not be indicated as it can increase the risk of infection. Providing a high-fiber diet immediately post-op is not recommended as the digestive system needs time to recover from surgery.
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When obtaining the nursing history of a 7-year-old child admitted to the hospital with acute glomerulonephritis (AGN), which finding should the nurse expect to obtain?
- A. High blood cholesterol level on routine screening.
- B. Increased thirst and urination.
- C. A recent strep throat infection.
- D. A recent DPT immunization.
Correct Answer: C
Rationale: When assessing a child with acute glomerulonephritis (AGN), a common trigger to expect in the nursing history is a recent strep throat infection. AGN can be triggered by a streptococcal infection, leading to the deposition of immune complexes in the glomeruli. This finding is crucial as it helps identify a potential cause for the development of AGN in the child. Choices A, B, and D are incorrect as high blood cholesterol levels, increased thirst and urination, and recent DPT immunization are not directly associated with triggering acute glomerulonephritis in children.
A 16-year-old adolescent is admitted to the hospital with a diagnosis of meningitis. The nurse notes that the client has a severe headache and photophobia. What is the nurse's priority action?
- A. Administer prescribed pain medication
- B. Place the client in a dark, quiet room
- C. Notify the healthcare provider
- D. Encourage the client to rest
Correct Answer: B
Rationale: The priority action for the nurse when a client with meningitis presents with a severe headache and photophobia is to place the client in a dark, quiet room. This intervention helps reduce stimuli that can exacerbate symptoms such as headache and photophobia. Creating a calm environment can provide relief and promote comfort for the client while also supporting their recovery. Administering pain medication may be necessary but ensuring a suitable environment takes precedence. Notifying the healthcare provider is important but is not the immediate priority. Encouraging rest is beneficial, but creating an appropriate environment to alleviate symptoms is the initial essential step.
What recommendation should the PN provide to help a 5-year-old girl who has started wetting the bed again after being dry at night for several months?
- A. Explain that bedwetting is normal in children and will pass with time.
- B. Advise limiting fluids in the evening and before bedtime.
- C. Suggest punishing the child for wetting the bed to prevent recurrence.
- D. Encourage the child to use the bathroom immediately before bed.
Correct Answer: D
Rationale: Encouraging the child to use the bathroom before bed is a helpful recommendation to prevent nighttime bedwetting. Bedwetting can sometimes reoccur due to stress or other factors, and ensuring the child empties their bladder before sleeping may reduce the likelihood of bedwetting episodes. Choice A is incorrect because while bedwetting is common in children, it is essential to provide practical solutions rather than just reassurance. Choice B is not the best option for a child who has recently started bedwetting again after being dry, as it may not address the underlying cause. Choice C is inappropriate and harmful as punishing the child for bedwetting can lead to psychological distress and worsen the situation.
The nurse is preparing to administer an immunization to a 5-year-old child. The parent asks if the vaccine can be given in a different way because the child is afraid of needles. What is the nurse's best response?
- A. We can apply a numbing cream before the injection
- B. There is no other way to administer this vaccine
- C. We can give the vaccine as a nasal spray
- D. We can skip the vaccine if the child is too afraid
Correct Answer: C
Rationale: Administering the vaccine as a nasal spray provides an alternative method of delivery that avoids the use of needles, addressing the child's fear while ensuring immunization. Nasal sprays are effective for certain vaccines and can be a suitable option in this scenario. Choice A is not the best response as it only addresses pain management but does not eliminate the use of needles. Choice B is incorrect as there are alternative delivery methods like nasal sprays. Choice D is incorrect as skipping the vaccine would leave the child unprotected and is not a recommended course of action.
The healthcare provider is preparing to administer digoxin (Lanoxin) to a 6-month-old infant with heart failure. The healthcare provider notes that the infant's heart rate is 90 beats per minute. What should the healthcare provider do next?
- A. Administer the medication as prescribed
- B. Hold the medication and notify the healthcare provider
- C. Reassess the heart rate in 30 minutes
- D. Administer half the prescribed dose
Correct Answer: B
Rationale: In this scenario, the correct action is to hold the medication and notify the healthcare provider. Digoxin should be withheld if the infant's heart rate is below 100 beats per minute. Administering digoxin in this situation can further slow down the heart rate in infants with heart failure, leading to potential adverse effects. Reassessing the heart rate in 30 minutes is not the best immediate action to take, as prompt notification and withholding of the medication are crucial. Administering the medication as prescribed or giving half the dose can exacerbate the situation by potentially further lowering the heart rate.