Nokea
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.
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The health care team wishes to establish a policy regarding sleep positions for infants with gastroesophageal reflux (GER). The first step should be to search for:
- A. Policies from other hospitals.
- B. Data from retrospective studies.
- C. Published national standards.
- D. Expert opinions.
Correct Answer: C
Rationale: National standards provide evidence-based guidance for policy development.
The nurse is caring for a child in Bryant's traction (see figure). The nurse should:
- A. Adjust the weights on the legs until the buttocks rest on the bed.
- B. Provide frequent skin care.
- C. Place a pillow under the buttocks.
- D. Remove the elastic leg wraps every 8 hours for 10 minutes.
Correct Answer: B
Rationale: Frequent skin care is essential in Bryant's traction to prevent pressure ulcers due to prolonged immobility.
A 13-month-old has a febrile seizure one month after the administration of the chickenpox vaccine. The nurse should:
- A. Recognize that the events are unrelated.
- B. Report the event through the Vaccine Adverse Event Reporting System.
- C. Explain to the parents that this is a rare but acceptable risk.
- D. Report the incident through the vaccine manufacturer's hotline.
Correct Answer: B
Rationale: Febrile seizures post-vaccination should be reported to VAERS for monitoring vaccine safety.
When teaching an adolescent with facial acne about skin care, the nurse should instruct the adolescent.
- A. Wash the face twice a day with mild soap and water.
- B. Remove whiteheads and comedones after washing his face with antibacterial soap.
- C. Apply vitamin E ointment twice daily to the affected skin.
- D. Apply tretinoin (Retin-A) daily in the morning and expose the face to the sun.
Correct Answer: A
Rationale: Washing the face twice daily with mild soap and water helps remove excess oil and debris without irritating the skin. Removing whiteheads can cause scarring, vitamin E is not evidence-based for acne, and tretinoin should be applied at night due to photosensitivity.
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.