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When advising a new mother on caring for a child with croup, which symptom should be a priority concern for the telephone triage nurse?
- A. Fever 101.0° F (38.3°C)
- B. Barking cough, worse at night
- C. Frequent crying during nursing
- D. Difficulty swallowing secretions .
Correct Answer: D
Rationale: Difficulty swallowing secretions suggests severe airway swelling, requiring urgent attention.
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The nurse is caring for an adolescent with type 1 diabetes mellitus who presents with an HbA1c of 11% (97 mmol/mol), thirst, and blurred vision. What action should the nurse take first?
- A. Obtain point-of-care glucose.
- B. Assess urine for ketones.
- C. Check blood pressure.
- D. Review prior insulin prescriptions.
Correct Answer: A
Rationale: Symptoms suggest hyperglycemia; point-of-care glucose testing confirms this and guides treatment.
The nurse is providing education to parents about preventing otitis media recurrence in their infant. Which instruction should the nurse include?
- A. Position prone after feeding.
- B. Breastfeed frequently.
- C. Avoid smoke exposure.
- D. Inspect the infant's ears daily.
Correct Answer: C
Rationale: Avoiding smoke exposure reduces eustachian tube irritation, lowering otitis media risk.
The nurse is teaching a school-age child with left femoral osteomyelitis and the child's parent before discharge. What instruction should the nurse give related to the initial phase of treatment?
- A. Ensure no weight bearing on the affected extremity
- B. Administer topical antibiotic therapy daily
- C. Schedule ice pack applications to the infected area
- D. Provide passive range of motion exercises
Correct Answer: A
Rationale: No weight bearing prevents further bone damage during the initial treatment phase of osteomyelitis, supporting infection control.
When developing a teaching plan for an adolescent male who was recently diagnosed with Type 1 diabetes mellitus, the nurse should instruct the client to consume a source of sugar if which symptom occurs?
- A. Seeing spots
- B. Profuse perspiration
- C. Racing pulse
- D. Excessive thirst
Correct Answer: B
Rationale: Profuse perspiration indicates hypoglycemia, requiring sugar intake to raise blood glucose.
The parents of a child who is diagnosed with Wilm's tumor ask the nurse why surgery is necessary before a biopsy is performed. What information should the nurse provide?
- A. The surgery provides a visualization of other pathology and dysfunction of the kidney.
- B. Surgery is necessary to stage the tumor and determine metastasis to other sites.
- C. Metal clips are surgically applied at the tumor site for exact marking for radiation.
- D. Biopsy may rupture the encapsulated tumor and cause the cancer cells to spread.
Correct Answer: D
Rationale: Biopsy risks rupturing the tumor, potentially spreading cancer cells.