Nokea
Which actions will the nurse implement?
- A. Assess rectal temperature every 4 hours.
- B. Administer acetaminophen as ordered.
- C. Assess skin turgor.
- D. Restrict fluids.
- E. Assess level of consciousness.
Correct Answer: B,C,E
Rationale: Administering acetaminophen, assessing skin turgor, and monitoring consciousness address fever and dehydration risks; rectal temperatures are avoided in pediatrics.
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Which observation on entering the hospital room lets the nurse know that there is a need for the parents to receive safety education to prevent unintentional injury?
- A. The blanket is not tucked into the mattress.
- B. Diapers and wipes are stacked at the foot of the crib.
- C. The crib side is locked in the up position.
- D. Pillows are stacked on the bedside table.
Correct Answer: B
Rationale: Diapers and wipes at the crib's foot pose a suffocation risk, indicating a need for parental safety education.
Which restraint is most appropriate for the insertion of an intravenous line in a scalp vein of an infant?
- A. Mummy
- B. Clove hitch
- C. Jacket
- D. Elbow
Correct Answer: A
Rationale: A mummy restraint immobilizes the infant safely for scalp vein IV insertion.
What factor does the nurse explain affects the infant's physiological response to medications?
- A. Faster metabolism in the liver
- B. Slower intestinal transit
- C. Immature kidney function
- D. Increased secretion of hydrochloric acid
Correct Answer: C
Rationale: Immature kidney function in infants under 1 year hinders effective drug excretion, affecting response.
After instilling nose drops, the nurse will keep the infant in the head down position for at least __ seconds.
Correct Answer: 30
Rationale: Retaining the head-down position for 30 seconds allows nose drops to penetrate deeply into the nostril.
Which strategy might the nurse use when administering oral medications to a young child who is reluctant?
- A. Mix the medication with chocolate milk.
- B. Tell the child that the medication is candy.
- C. Give the medication quickly if the child is crying.
- D. Offer the child fruit juice after the medication is swallowed.
Correct Answer: D
Rationale: Offering fruit juice after swallowing medication encourages cooperation without compromising nutrient intake.