Nokea
When providing care for a child in balanced suspension skeletal traction using a Thomas splint and Pearson attachment to the right femur, which intervention is most important for the nurse to implement?
- A. Change position every 2 hours.
- B. Monitor peripheral pulses and sensation in the right leg.
- C. Cleanse pin sites as prescribed.
- D. Assess skin for redness and signs of tissue breakdown.
Correct Answer: B
Rationale: Monitoring pulses and sensation detects vascular or nerve compromise, critical in traction care.
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A child who weighs 18 pounds receives a prescription for amoxicillin 25 mg/kg/day by mouth in divided doses every 12 hours. The bottle is labelled, 'Amoxicillin for Oral Suspension, USP 400 mg per 5 mL.' How many mL should the nurse administer with each dose?
- A. 1.3 mL
Correct Answer: A
Rationale: The dose is calculated as 18 lbs ÷ 2.2 = 8.18 kg, 25 mg/kg/day x 8.18 kg = 204.5 mg/day, divided into 102.25 mg/dose. Then, 102.25 mg ÷ (400 mg/5 mL) = 1.3 mL.
The nurse is assessing an infant with aortic stenosis and identifies bilateral fine crackles in both lung fields. Which additional finding should the nurse expect to obtain?
- A. Hemiplegia.
- B. Fever.
- C. Vigorous feeding and satiation.
- D. Hypotension and tachycardia.
Correct Answer: D
Rationale: Aortic stenosis can lead to heart failure and pulmonary edema, causing bilateral fine crackles, with hypotension and tachycardia as additional signs of decreased cardiac output.
The nurse is providing treatment education to the caregiver of a school-age child recently diagnosed with attention-deficit/hyperactivity disorder (ADHD). Which statement(s) made by the caregiver demonstrate an understanding of the education?
- A. Understanding that nonstimulant medications show little benefit in treatment.
- B. Designating an established area for study.
- C. Anticipating being automatically entered into a specialized education plan.
- D. Knowing that medication is not always the best approach to treatment.
- F. Maintaining a consistent home schedule.
Correct Answer: B,D,F
Rationale: Designating a study area, recognizing non-medication approaches, and maintaining a consistent schedule support ADHD management, while nonstimulants can be effective, and IEPs are not automatic.
The nurse is monitoring a child with hydrocephalus who received a repeat ventriculoperitoneal (VP) shunt yesterday. Which assessment finding indicates to the nurse that the shunt is functioning normally?
- A. The child has grown in height since the previous shunt placement.
- B. The child is afebrile with normal vital signs postoperatively.
- C. An intracranial pressure (ICP) monitoring probe is in place.
- D. The child reports no evidence of continuous headaches.
Correct Answer: D
Rationale: The absence of continuous headaches indicates the VP shunt is functioning normally by relieving pressure on the brain, a primary symptom of hydrocephalus.
The nurse is giving an intramuscular injection of an antibiotic to a 16-month-old toddler with pneumonia. The toddler does not have any known allergies and has been walking without assistance for one month. Which technique should the nurse select for administration?
- A. Give in the arm, one to 2 inches (2.5 to 5.0 cm) below the acromion process.
- B. Use a needle length of 1/2 inch (1.25 cm) to avoid deep tissue damage.
- C. Administer the injection into the middle of the lateral aspect of the thigh.
- D. Divide the gluteal area into quarters and give IM into the upper outer quadrant.
Correct Answer: C
Rationale: The lateral thigh is the recommended IM injection site for toddlers, minimizing nerve and vessel damage.