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When planning a 15-month-old toddler's daily diet with the parents, which of the following amounts of milk should the nurse include?
- A. 1/2 to 1 cup.
- B. 2 to 3 cups.
- C. 4 to 5 cups.
Correct Answer: B
Rationale: Toddlers need 2-3 cups of milk daily to meet nutritional needs.
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A 6-month old infant has had a cardiac arrest and the rapid response team has been paged. The nurse arrives in the client's room and observes a physician assistant (PA) administering CPR to an infant (see figure). To assist the PA with CPR, the nurse should:
- A. Tell the PA to use the heel of the hand on the infant's sternum.
- B. Place one hand on the infant's sternum for chest compressions while the PA ventilates the lungs at a rate of one breath to every 5 compressions.
- C. Obtain an Ambu bag and give breaths at a rate of 2 breaths per 15 compressions.
- D. Encircle the infant's chest with the thumbs=on top to provide compression while the PA uses an Ambu bag to administer rescue breaths after every 15 compressions.
Correct Answer: C
Rationale: For an infant, the nurse should obtain an Ambu bag and deliver 2 breaths per 15 compressions, following pediatric CPR guidelines for 2-rescuer CPR.
A 14-year-old girl with sickle cell disease has her fourth hospitalization for sickle cell crisis. Her family is planning a ski vacation in the mountains. What should the nurse tell the parents?
- A. Encourage them to go on the trip.
- B. Go on the trip, but find a sitter for the 14-year-old.
- C. Suggest the trip be postponed until next year.
- D. Explain that the high altitude may cause a crisis.
Correct Answer: D
Rationale: High altitudes reduce oxygen availability, increasing the risk of sickle cell crisis due to hypoxia. This is a critical consideration for the child's safety.
When planning home care for the child with Legg-Calvé-Perthes disease, what should be the primary focus for family teaching?
- A. Need for intake of protein-rich foods.
- B. Little stretching exercises for both legs.
- C. Management of the corrective appliance.
- D. Relaxation techniques for pain control.
Correct Answer: C
Rationale: Management of the corrective appliance, such as a brace or traction, is the primary focus to ensure proper use and compliance, which is critical for treatment success.
Which action should the nurse do first when noting clear drainage on the child's dressing and bed linen after a craniotomy for a brain tumor?
- A. Change the dressing.
- B. Elevate the head of the bed.
- C. Test the fluid for glucose.
- D. Notify the physician.
Correct Answer: C
Rationale: Clear drainage may indicate cerebrospinal fluid leak, which testing for glucose can confirm, guiding further action.
A nurse is teaching the parents of a child diagnosed with a urinary tract infection secondary to vesicoureteral reflux. How should the nurse explain how the reflux contributes to the infection?
- A. It prevents complete emptying of the bladder.
- B. It causes urine backflow into the kidney.
- C. It results in painful bladder spasms.
- D. It causes painful urination.
Correct Answer: B
Rationale: Reflux allows bacteria to reach kidneys.