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When caring for a child with moderate burns from the waist down, which of the following should the nurse do when positioning the child?
- A. Place the child in a position of comfort.
- B. Allow the child to lie on the abdomen.
- C. Ensure the application of leg splints.
- D. Have the child flex the hips and knees.
Correct Answer: D
Rationale: Flexing hips and knees prevents contractures and promotes circulation in lower extremity burns. Comfort is secondary, lying on the abdomen may cause pressure, and splints are not routinely needed.
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The physician orders carbamazepine extended release (Tegretol-XR) for a client with cerebral palsy who also has a seizure disorder. The client has a gastrostomy feeding tube. What should the nurse do?
- A. Crush the medication and administer through the tube.
- B. Request an immediate-release formulation.
- C. Withhold the medication and notify the physician.
- D. Administer the medication orally.
Correct Answer: C
Rationale: Extended-release formulations like Tegretol-XR should not be crushed; the nurse should notify the physician to adjust the order.
An adolescent sustains a T3 spinal cord injury. After insertion of an intravenous line, a nasogastric tube, and an indwelling urinary (Foley) catheter, the adolescent is admitted to the intensive care unit. What should the nurse do next when assessment reveals that the adolescent's feet and legs are cool to the touch?
- A. Cover the adolescent's legs with blankets.
- B. Report this finding to the physician immediately.
- C. Reposition the adolescent's legs.
- D. Lay the adolescent flat to aid circulation.
Correct Answer: A
Rationale: Cool extremities indicate poor circulation, common in spinal cord injury; covering with blankets promotes warmth and comfort.
When assessing an infant with an undescended testis, the nurse should be alert for which of the following?
- A. Abnormal lower extremity reflexes.
- B. A history of frequent emesis.
- C. A bulging in the inguinal area.
- D. Poor weight gain.
Correct Answer: C
Rationale: An inguinal bulge may indicate an undescended testis.
The health care provider has ordered a sterile urine specimen on a 3-year-old boy with a history of recurrent urinary tract infections. The family is upset because the last time the child was catheterized the procedure was very painful and traumatic. The nurse should tell the family:
- A. I will request an order for a sedative to help him relax.
- B. I can't do anything to reduce the pain
- C. but you can hold him during the procedure.
- D. I will get an order for a lidocaine-based lubricant to make the procedure more comfortable.
- E. I can apply a topical anesthetic 20 minutes before placing the catheter.
Correct Answer: D
Rationale: Topical anesthetics can minimize discomfort.
During a developmental screening, the nurse finds that a 3-year-old child with cerebral palsy has arrested social and language development. The nurse tells the family:
- A. This is a sign the cerebral palsy is progressing.'
- B. Your child has reached his maximum language abilities.'
- C. I need to refer you for more developmental testing.'
- D. We need to modify your therapy plan.'
Correct Answer: C
Rationale: Arrested development requires further evaluation to determine the cause and appropriate interventions, so referral for additional testing is necessary.