Nokea
What is the priority nursing intervention when caring for a neonate born with bladder exstrophy?
- A. Measuring intake and output
- B. Inserting a Foley catheter
- C. Covering the defect with sterile plastic wrap
- D. Palpating the bladder mass to ensure urine is expelled
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
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The healthcare provider is caring for a child on bed rest who has severe edema in the left lower extremity due to blocked lymphatic drainage. Which nursing diagnosis would take priority?
- A. Risk for Impaired Skin Integrity
- B. Risk for Altered Body Image
- C. Risk for Imbalanced Nutrition: Less Than Body Requirements
- D. Risk for Activity Intolerance
Correct Answer: A
Rationale: The priority nursing diagnosis in this scenario is 'Risk for Impaired Skin Integrity' because severe edema in the left lower extremity can lead to compromised circulation and pressure ulcers, increasing the risk of skin breakdown and infection. Addressing and preventing impaired skin integrity is crucial for the child's overall health and well-being.
A parent of a child with oral candidiasis is being taught by a nurse. Which statement by the parent indicates an understanding of the teaching?
- A. I will boil the nipples and pacifiers for 20 minutes each day.
- B. I will stop the medication as soon as the spots disappear.
- C. I will apply an over-the-counter steroid cream to the spots.
- D. I will mix the medication in my child's bottle.
Correct Answer: A
Rationale: Boiling the nipples and pacifiers for 20 minutes each day is an appropriate measure to prevent reinfection of oral candidiasis. This practice helps eliminate the Candida fungus from these items, reducing the risk of the child getting reinfected. It is crucial for the parent to follow this hygienic practice consistently to ensure the child's recovery and prevent the spread of the infection.
The patient is receiving a heparin infusion for the treatment of pulmonary embolism. Which assessment finding is most likely related to an adverse effect of heparin?
- A. HR of 60 bpm
- B. BP of 160/88
- C. Discolored urine
- D. Inspiratory wheezing
Correct Answer: C
Rationale: The primary and most serious adverse effect of heparin is bleeding. However, discolored urine can indicate bleeding into the urinary tract, which is a potential adverse effect of heparin therapy. While changes in heart rate (HR) and blood pressure (BP) can occur due to various reasons, discolored urine specifically points towards a potential adverse effect related to heparin therapy.
Upper respiratory infections (URI) in children may increase the risk of reactive airway disease. Which of the following is NOT a typical feature of URI?
- A. Fever
- B. Clear rhinorrhea
- C. Injected sclerae
- D. Productive cough
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A nurse is planning care for a 2-month-old infant who is postoperative following surgical repair of a cleft lip. Which of the following actions should the nurse take?
- A. Position the infant on his abdomen
- B. Cleanse the incision site with hydrogen peroxide
- C. Offer the infant a pacifier
- D. Keep the infant's elbow restrained
Correct Answer: D
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.