Nokea
The toddler with nephrotic syndrome exhibits generalized edema. Which of the following measures should the nurse institute for this child with a nursing diagnosis of Impaired skin integrity related to edema?
- A. Ambulate every shift while awake.
- B. Apply lotion on opposing skin surfaces.
- C. Apply powder to skinfolds.
- D. Separate opposing skin surfaces with soft cloth.
Correct Answer: D
Rationale: Prevent skin breakdown.
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A transfusion of packed red blood cells has been ordered for a 1-year-old with sickle cell anemia. The infant has a 25 gauge I.V. infusing dextrose with sodium and potassium. Using the Situation, Background, Assessment, Recommendation (SBAR) method of communication, the nurse contacts the physician and recommends:
- A. Starting a second I.V. with a 22 gauge catheter to infuse normal saline with the blood.
- B. Using the existing I.V., but changing the fluids to normal saline for the transfusion.
- C. Replacing the I.V. with a 22 gauge catheter to infuse the ordered fluids.
- D. Starting a second I.V. with a 25 gauge catheter to infuse normal saline with the transfusion.
Correct Answer: A
Rationale: A second I.V. with a larger 22-gauge catheter ensures safe blood transfusion, as dextrose is incompatible and a 25-gauge is too small.
The parents of a 9-month-old bring the infant to the clinic for a regular checkup. The infant has received no immunizations. Which of the following would be appropriate for the nurse to administer at this visit?
- A. Diphtheria, tetanus, and acellular pertussis (DTaP); Haemophilus influenzae type B (Hib); inactivated poliomyelitis vaccine (IPV); and purified protein derivative (PPD).
- B. DTaP; Hib; oral polio vaccine (OPV); and measles, mumps, and rubella (MMR).
- C. PPD, MMR, hepatitis B (hepB), and OPV.
- D. HepB, IPV, Hib, and varicella.
Correct Answer: A
Rationale: These vaccines align with catch-up schedules for a 9-month-old, except PPD, which is a test, not a vaccine.
The nurse assesses the family's ability to cope with the child's cerebral palsy. Which action should alert the nurse to the possibility of their inability to cope with the disease?
- A. Limiting interaction with extended family and friends.
- B. Learning measures to meet the child's physical needs.
- C. Requesting teaching about cerebral palsy in general.
- D. Not seeking financial help to pay for medical bills.
Correct Answer: A
Rationale: Limiting social interactions may indicate social isolation, a sign of poor coping, whereas the other options suggest proactive engagement with the child's needs.
The mother brings her child to the clinic after discharge from the hospital for Guillain-Barré syndrome. Which of the following statements by the mother indicates that she is following the discharge plan?
- A. She and her sister argue all day.'
- B. I have to bribe her to get her to do her exercises.'
- C. I take her to the pool where she can exercise with other children.'
- D. She's missed a few of her therapy sessions because she often sleeps.'
Correct Answer: C
Rationale: Exercising in the pool indicates adherence to the rehabilitation plan, promoting recovery through low-impact activity.
After 6 months of treatment with diet and exercise, a 12-year-old with type 2 diabetes still has a fasting blood glucose level of 140 mg/dL. The primary care provider has decided to begin metformin (Glucophage). The adolescent asks how the medication works. The nurse should tell the client that the medicine decreases the glucose production and:
- A. Replaces natural insulin.
- B. Helps the body make more insulin.
- C. Increases insulin sensitivity.
- D. Decreases carbohydrate adsorption.
Correct Answer: C
Rationale: Metformin reduces hepatic glucose production and increases insulin sensitivity in peripheral tissues, improving glucose uptake. It does not replace insulin, stimulate insulin production, or affect carbohydrate absorption.