Nokea
Which assessment finding should the nurse report immediately to the charge nurse or physician?
- A. Clear, watery nasal drainage
- B. Glasgow Coma Scale score of 15
- C. Child does not know the time of day
- D. Apical pulse of 80 beats/minute
Correct Answer: A
Rationale: Clear, watery nasal drainage may indicate cerebrospinal fluid (CSF) leakage, a serious complication of head injury requiring immediate reporting to prevent infection or neurological damage.
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The agitated father of the 12-hour-old newborn reports to the nurse that his baby’s hands and feet are blue. The nurse confirms acrocyanosis and intervenes by taking which action?
- A. Immediately stimulates the infant to cry
- B. Explain that this is normal in a newborn
- C. Assess the newborn’s temperature
- D. Assess the newborn’s cardiac status
Correct Answer: B
Rationale: Acrocyanosis blueness of hands and feet is a normal newborn phenomenon in the first 24 to 48 hours after birth. The nurse should explain this to relieve anxiety. Stimulation temperature or cardiac assessments are unnecessary.
Which instruction is most appropriate to give to the client regarding doxycycline?
- A. The medication normally causes a dark orange discoloration of urine.
- B. Take the medication 1 hour before or 2 hours after a meal.
- C. Don't drink water for at least 30 minutes after taking the medication.
- D. Report any symptoms of GI upset to the health care provider.
Correct Answer: B
Rationale: Doxycycline should be taken on an empty stomach (1 hour before or 2 hours after a meal) to ensure optimal absorption, making this the most appropriate instruction.
If the following snacks are available, which one is best to meet the child's need for protein?
- A. Strawberry milkshake
- B. A popsicle stick with cinnamon
- C. Cubes of flavored gelatin
- D. Warmed beef broth
Correct Answer: D
Rationale: Warmed beef broth is a high-protein snack suitable for a burn patient, providing protein needed for tissue repair and wound healing, unlike the other options, which are lower in protein.
When is the correct time for the nurse to administer the child's morning dose of a combination regular and NPH insulin?
- A. 30 minutes before breakfast is served
- B. 15 minutes before breakfast is served
- C. 30 minutes after breakfast is served
- D. 15 minutes after breakfast is served
Correct Answer: A
Rationale: Regular insulin peaks in 2-4 hours, and NPH peaks in 4-12 hours. Administering the combination 30 minutes before breakfast aligns insulin onset with food intake, controlling postprandial glucose levels effectively.
Which nursing action best facilitates the child's reestablishment of friendships with peers?
- A. Encourage the child to make friends with children who have cancer.
- B. Tell the child that real friends do not care how you look on the outside.
- C. Encourage the child's friends to visit while the child is still in the hospital.
- D. Tell the child that the appearance changes are temporary and not that bad.
Correct Answer: C
Rationale: Encouraging friends to visit in the hospital maintains social connections, supporting the child's emotional well-being and facilitating reintegration with peers.