Nokea
When planning care for a newborn with esophageal atresia and tracheoesophageal fistula, which is the priority nursing diagnosis?
- A. Ineffective Tissue Perfusion
- B. Ineffective Infant Feeding Pattern
- C. Acute Pain
- D. Risk for Aspiration
Correct Answer: D
Rationale: The priority nursing diagnosis for a newborn with esophageal atresia and tracheoesophageal fistula is 'Risk for Aspiration' because of the potential respiratory complications associated with these conditions. The newborn is at a higher risk of aspirating oral or gastric contents due to the abnormal connections between the esophagus and trachea, posing a serious threat to the airway and lungs. Addressing this risk is crucial to prevent respiratory distress and maintain the airway's patency, making it the priority nursing diagnosis in this scenario.
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Which question does not provide information regarding the family's cultural values?
- A. Who makes the decisions?
- B. What is the child's date of birth?
- C. What are the daily routines and rules of mealtime?
- D. What do the parents believe about disability?
Correct Answer: B
Rationale: The correct answer is B. Asking for the child's date of birth is a factual question that does not directly relate to the family's cultural values. The other choices (A, C, D) explore aspects that could provide insights into the family's cultural values and beliefs, such as decision-making dynamics, daily routines, mealtime rules, and views on disability.
What is the most appropriate nursing consideration for a patient who is prescribed verapamil and digoxin?
- A. Restrict intake of oral fluids and high-fiber foods
- B. Take an apical pulse for 30 seconds before administration
- C. Notify the healthcare provider of nausea, vomiting, and visual changes
- D. Hold the medications if the heart rate is greater than 110 bpm
Correct Answer: C
Rationale: When a patient is prescribed verapamil and digoxin, it is crucial to monitor for signs of digoxin toxicity due to the potential interaction between these medications. Verapamil can elevate digoxin blood serum levels, increasing the risk of toxicity. Symptoms of digoxin toxicity include nausea, vomiting, and visual changes. Restricting intake of oral fluids and high-fiber foods is not a specific consideration related to this medication combination. Before administering digoxin, it is essential to take an apical pulse for a full minute, not just 30 seconds. Additionally, holding the medications if the heart rate exceeds 110 bpm is not a typical response to the combination of verapamil and digoxin, which can cause bradycardia rather than tachycardia.
A 6-year-old male child presented with a cerebellar mass; after undergoing complete surgical resection of the mass, the histology of the mass reveals pilocytic astrocytoma. Of the following, the MOST appropriate next step in the management is
- A. radiotherapy
- B. chemotherapy
- C. observation
- D. concomitant chemo-radiotherapy
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
A nurse is providing teaching to the guardian of an infant about home safety. Which of the following statements by the guardian indicates an understanding of the teaching?
- A. I will place my baby on her stomach to sleep
- B. I will put a small pillow in my baby's crib
- C. I will keep my baby's crib away from the radiator
- D. I will use a drop-side crib for my baby
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.
Which clinical manifestations should the nurse anticipate upon assessment for a preschool-age child with a urinary tract infection (UTI)?
- A. Headache, hematuria, and vertigo
- B. Foul-smelling urine, elevated blood pressure (BP), and hematuria
- C. Urgency, dysuria, and fever
- D. Severe flank pain, nausea, and headache
Correct Answer: C
Rationale: Failed to generate a rationale of 500+ characters after 5 retries.