Nokea
When performing cardiopulmonary resuscitation (CPR), which of the following indicates that external chest compressions are effective?
- A. Mottling of the skin.
- B. Pupillary dilation.
- C. Palpable pulse.
- D. Cool, dry skin.
Correct Answer: C
Rationale: A palpable pulse during CPR indicates effective chest compressions, as it confirms adequate circulation.
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Immediately on return to the nursing unit after surgical repair of a cleft palate, in which of the following positions should the nurse place the child?
- A. On the back with the head in a position of comfort.
- B. In low Fowler's position with the head turned to the side.
- C. Lying on the abdomen with the head turned to the side.
- D. In reverse Trendelenburg with the head tilted forward.
Correct Answer: C
Rationale: Lying on the abdomen with the head turned to the side facilitates drainage and reduces the risk of aspiration post-surgery.
A child with Kawasaki disease is receiving low dose aspirin. The mother calls the clinic and states that the child has been exposed to influenza. Which recommendations should the nurse make?
- A. Increase fluid intake.
- B. Stop the aspirin.
- C. Keep the child home from school.
- D. Watch for fever.
- E. Weigh the child daily.
Correct Answer: B,C,D
Rationale: Aspirin should be stopped due to the risk of Reye's syndrome with influenza. Keeping the child home and monitoring for fever help manage infection risk.
When developing a recreational therapy plan of care for a 3-year-old child hospitalized with pneumonia and cystic fibrosis, which of the following toys would be appropriate?
- A. 100-piece jigsaw puzzle.
- B. Child's favorite doll.
- C. Fuzzy stuffed animal.
- D. Scissors, paper, and paste.
Correct Answer: B
Rationale: A child's favorite doll is appropriate for a 3-year-old, providing comfort and familiarity without posing a risk of irritation or infection, unlike fuzzy stuffed animals which can harbor dust or bacteria.
When observing the parent instilling prescribed ear drops ordered twice a day for a toddler, the nurse decides that the teaching about positioning of the pinna for instillation of the drops is effective when the parent pulls the toddler's pinna in which of the following directions?
- A. Up and forward.
- B. Up and backward.
- C. Down and forward.
- D. Down and backward.
Correct Answer: D
Rationale: In children under 3, the pinna is pulled down and back to straighten the ear canal.
A mother asks, "How should I bathe my baby now that he's had surgery for his inguinal hernia?" Which of the following instructions should the nurse give the mother?
- A. Clean his face and diaper area for 2 weeks.
- B. Use sterile sponges to cleanse the inguinal incision.
- C. Give him a sponge bath daily for 1 week.
- D. Give the infant full tub baths every day.
Correct Answer: C
Rationale: Sponge baths for 1 week keep the incision dry and reduce infection risk.