Nokea
When providing intermittent nasogastric feedings to an infant with failure to thrive, which method is preferred to confirm tube placement before each feeding?
- A. Obtain a chest X-ray.
- B. Verify that the gastric pH is less than 5.5.
- C. Auscultate the stomach while instilling an air bolus.
- D. Compare the tube insertion length to a standardized chart.
Correct Answer: B
Rationale: Gastric pH <5.5 confirms stomach placement non-invasively. X-rays are impractical for each feeding, auscultation is unreliable, and length comparison doesn't verify placement.
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Shortly after an infant is returned to his room following hydrocele repair, the infant's mother tells the nurse that the child's scrotum looks swollen and bruised. Which of the following responses by the nurse would be most appropriate?
- A. Let me see if the doctor has ordered aspirin for him. If he did
- B. I'll get it right away.
- C. Why don't you wait in his room? Then you can ask me any questions when I get there.
- D. What you are describing is unusual after this type of surgery. I'll let the doctor know.
- E. This is normal after this type of surgery. Let's look at it together just to be sure.
Correct Answer: D
Rationale: Swelling and bruising post-surgery are common.
At a follow-up appointment after being hospitalized, an adolescent with a history of cystic fibrosis (CF) describes his stools to the nurse. Which of the following descriptions should the nurse interpret as indicative of continued problems with malabsorption?
- A. Soft with little odor.
- B. Large and foul-smelling.
- C. Loose with bits of food.
- D. Hard with streaks of blood.
Correct Answer: B
Rationale: Large, foul-smelling stools indicate malabsorption in cystic fibrosis, suggesting inadequate pancreatic enzyme replacement or ongoing pancreatic insufficiency.
The nurse assesses the family's ability to cope with the child's cerebral palsy. Which action should alert the nurse to the possibility of their inability to cope with the disease?
- A. Limiting interaction with extended family and friends.
- B. Learning measures to meet the child's physical needs.
- C. Requesting teaching about cerebral palsy in general.
- D. Not seeking financial help to pay for medical bills.
Correct Answer: A
Rationale: Limiting social interactions may indicate social isolation, a sign of poor coping, whereas the other options suggest proactive engagement with the child's needs.
Which of the following is a normal response from an adolescent who has just returned to her room after an appendectomy?
- A. I'll need plastic surgery for this scar.
- B. I'm worried about the size of my scar.
- C. I don't want to have any pain.
- D. What will my boyfriend say about the scar?
Correct Answer: B
Rationale: Concern about scar size is a typical adolescent response, reflecting body image concerns.
The nurse is teaching the parents of a child with myelomeningocele how to prevent urinary tract infections. What should the care plan include for this child? Select all that apply.
- A. Provide meticulous skin care.
- B. See the seeds's maneuver to empty the bladder.
- C. Encourage frequent emptying of the bladder.
- D. Assure adequate fluid intake.
- E. Use tight-fitting diapers around the meatus.
Correct Answer: A,C,D
Rationale: Meticulous skin care prevents skin breakdown and infection. Frequent bladder emptying and adequate fluid intake reduce urinary stasis and bacterial growth. The 'seeds's maneuver' is likely a typo for Credé's maneuver, which is not always appropriate without medical guidance. Tight diapers can cause irritation and increase infection risk.