What advice should be provided by the practical nurse to the mother of a school-age child with acute diarrhea and mild dehydration who is occasionally vomiting despite being given an oral rehydration solution (ORS)?
- A. Continue to give ORS frequently in small amounts.
- B. Alternate between ORS and carbonated beverages.
- C. Take the child to the hospital for intravenous fluids.
- D. Place the child NPO for the next eight to nine hours.
Correct Answer: A
Rationale: The practical nurse should advise the mother to continue providing the oral rehydration solution (ORS) frequently in small amounts. It is essential to continue ORS administration to prevent dehydration, even if the child is occasionally vomiting. Small, frequent amounts of ORS help maintain hydration levels in children with acute diarrhea and mild dehydration.
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During a follow-up clinical visit, a mother tells the nurse that her 5-month-old son, who had surgical correction for tetralogy of Fallot, has rapid breathing, often takes a long time to eat, and requires frequent rest periods. The infant is not crying while being held, and his growth is in the expected range. Which intervention should the nurse implement?
- A. Stimulate the infant to cry to produce cyanosis
- B. Auscultate the heart and lungs while the infant is held
- C. Evaluate the infant for failure to thrive
- D. Obtain a 12-lead electrocardiogram
Correct Answer: B
Rationale: Auscultating the heart and lungs while the infant is held can provide important diagnostic information in assessing the cardiac and respiratory status of the infant who had surgical correction for tetralogy of Fallot. This intervention can help the nurse identify any abnormal heart or lung sounds, which may indicate complications or issues that need further evaluation or intervention.
A 5-year-old child with leukemia is receiving chemotherapy. The nurse notes that the child's white blood cell count is low. What is the nurse's priority intervention?
- A. Administer antibiotics as prescribed
- B. Place the child in protective isolation
- C. Encourage the child to eat a balanced diet
- D. Teach the parents about infection prevention
Correct Answer: B
Rationale: The priority intervention for a 5-year-old child with leukemia receiving chemotherapy and having a low white blood cell count is to place the child in protective isolation. This intervention helps reduce the risk of infection, which is crucial in this immunocompromised state. Protective isolation aims to limit the child's exposure to pathogens and promote their safety during a period of increased vulnerability to infections.
The healthcare professional working on the pediatric unit takes two 8-year-old girls to the playroom. Which activity is best for the healthcare professional to plan for these girls?
- A. Selecting a board game.
- B. Playing doctor and patient.
- C. Watching cartoons on TV.
- D. Coloring, cutting, and pasting.
Correct Answer: A
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A 2-year-old child with heart failure (HF) is admitted for replacement of a graft for coarctation of the aorta. Prior to administering the next dose of digoxin (Lanoxin), the nurse obtains an apical heart rate of 128 bpm. What action should the nurse take?
- A. Determine the pulse deficit.
- B. Administer the scheduled dose.
- C. Calculate the safe dose range.
- D. Review the serum digoxin level.
Correct Answer: B
Rationale: Administering the scheduled dose is appropriate in this scenario since the heart rate of 128 bpm is within an acceptable range for a 2-year-old child with heart failure. Monitoring for signs of digoxin toxicity is important; however, the immediate action required is to administer the scheduled dose as prescribed based on the heart rate assessment.
A 16-year-old female student with a history of asthma controlled with both an oral antihistamine and an albuterol (ProAir) metered-dose inhaler (MDI) comes to the school nurse. The student complains that she cannot sleep at night, feels shaky, and her heart feels like it is 'beating a mile a minute.' Which information is most important for the nurse to obtain?
- A. When she last took the antihistamine.
- B. When her last asthma attack occurred.
- C. Duration of most asthma attacks.
- D. How often the MDI is used daily.
Correct Answer: D
Rationale: The most crucial information for the nurse to obtain in this scenario is how often the metered-dose inhaler (MDI) is used daily. This information will help assess if the symptoms of insomnia, shakiness, and palpitations are potentially related to overuse of the inhaler, which can cause side effects such as tremors and palpitations. Monitoring the frequency of MDI usage is essential in managing asthma and ensuring appropriate medication administration.
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