Nokea
When developing the plan of care for a school-age child with a suspected diagnosis of appendicitis who is complaining of severe abdominal pain, which of the following measures should the nurse expect to include in the child's plan of care?
- A. Application of a heating pad.
- B. Insertion of a rectal tube.
- C. Application of an ice bag.
- D. Administration of an intravenous narcotic.
Correct Answer: C,D
Rationale: Ice and narcotics relieve pain without risking perforation, unlike heat or rectal tubes.
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The nurse is planning care for a child with hemophilia who is scheduled for a dental procedure. Which precaution should the nurse include?
- A. Administer ibuprofen for post-procedure pain.
- B. Schedule the procedure without prior preparation.
- C. Ensure factor replacement therapy is given before the procedure.
- D. Encourage vigorous rinsing of the mouth post-procedure.
Correct Answer: C
Rationale: Factor replacement therapy before dental procedures prevents excessive bleeding in hemophilia. Ibuprofen and vigorous rinsing increase bleeding risk.
A nurse administers ranitidine (Zantac) instead of cetirizine (Zyrtec) to an 8-year-old with asthma. The client has suffered no adverse effects. The nurse tells the charge nurse of the incident but fears disciplinary action. The charge nurse should tell the nurse:
- A. If you do not report the error, I will have to.
- B. Reporting the error helps to identify system problems to improve client safety.
- C. Notify the client's physician to see if she wants this reported.
- D. This is not a serious mistake so reporting it will not affect your position.
Correct Answer: B
Rationale: Reporting the error helps identify system problems to improve client safety, promoting a culture of transparency and quality improvement.
A nurse is teaching parents of a child with PKU about dietary management. Which instruction is most important?
- A. Avoid all fruits and vegetables.
- B. Monitor phenylalanine levels regularly.
- C. Use high-protein supplements.
- D. Limit water intake.
Correct Answer: B
Rationale: Regular monitoring of phenylalanine levels ensures dietary compliance and prevents toxicity. Fruits and vegetables are allowed, high-protein foods are avoided, and water restriction is unnecessary.
Which of the following statements by the mother of a toddler diagnosed with nephrotic syndrome indicates that the mother has understood the nurse's teaching about this disease?
- A. My child really likes chips and bologna. I guess we'll have to find something else.
- B. We'll have to encourage lots of liquids. Did you say about 4 liters every day?
- C. We worry about the surgery. Do you think we should do direct donation of blood?
- D. We understand the need for antibiotics. I just wish the antibiotics could be given by mouth.
Correct Answer: A
Rationale: Shows understanding of dietary restrictions.
A nurse is teaching the parents of a child newly diagnosed with celiac disease. Which food should the nurse instruct them to avoid?
- A. Rice.
- B. Wheat.
- C. Corn.
- D. Potatoes.
Correct Answer: B
Rationale: Celiac disease requires a gluten-free diet, avoiding wheat, barley, and rye. Rice, corn, and potatoes are gluten-free and safe.