Nokea
When preparing to deliver back slaps to an infant who is choking on a foreign body, in which of the following positions should the nurse position the infant?
- A. Head down and lower than the trunk.
- B. Head up and raised above the trunk.
- C. Head to one side and even with the trunk.
- D. Head parallel to the nurse and supported at the buttocks.
Correct Answer: A
Rationale: Positioning the infant head down and lower than the trunk facilitates dislodgement of the foreign body by gravity during back slaps.
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After a child undergoes nephrectomy for a Wilms' tumor, the nurse should assess the child postoperatively for which early sign of a complication?
- A. Increased abdominal distention.
- B. Elevated blood pressure.
- C. Increased respiratory rate.
- D. Increased urine output.
Correct Answer: A
Rationale: Distention suggests internal bleeding.
The nurse should instruct the family of a child with newly diagnosed hyperthyroidism to:
- A. Keep their home warmer than usual.
- B. Encourage twenty or outdoor activities.
- C. Promote interactions with one friend instead of groups.
- D. Limit bathing to prevent skin irritation.
Correct Answer: C
Rationale: Hyperthyroidism causes irritability and hyperactivity, so limiting social interactions to one friend reduces overstimulation. Warmer homes, excessive activity, and limited bathing are inappropriate.
Which of the following should the nurse include when completing discharge instructions for the parents of a 12-month-old child diagnosed with Kawasaki disease (KD) and being discharged to home?
- A. Offer the child extra fluids every 2 hours for 2 weeks.
- B. Take the child's temperature daily for several days.
- C. Check the child's blood pressure daily until the follow-up appointment.
- D. Call the physician if the irritability lasts for 2 more weeks.
Correct Answer: B
Rationale: Monitoring temperature daily helps detect persistent fever, a sign of ongoing inflammation in Kawasaki disease. Other options are less critical or impractical at home.
A nurse is planning a diet for a client with cystic fibrosis. Which of the following foods should not be included in the meal plan?
- A. Roasted chicken.
- B. Fried scallops.
- C. Milk shake.
- D. Egg omelet.
Correct Answer: B
Rationale: Fried scallops are high in fat and difficult to digest for a client with cystic fibrosis due to pancreatic insufficiency. A high-calorie, high-protein diet with moderate fat and pancreatic enzyme supplements is more appropriate.
When obtaining the initial health history from a 10-year-old child with abdominal pain and suspected appendicitis, which of the following questions would be most helpful in eliciting data to help support the diagnosis?
- A. Where did the pain start?
- B. What did you do for the pain?
- C. How often do you have a bowel movement?
- D. Is the pain continuous, or does it let up?
Correct Answer: A
Rationale: Pain starting near the umbilicus and migrating to the right lower quadrant is characteristic of appendicitis.