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A nurse is caring for an infant who has coarctation of the aorta.
Which finding should the nurse identify as expected?
- A. Weak femoral pulses
- B. Bounding pulses in the lower extremities
- C. Cyanosis of the hands and feet
- D. Frequent episodes of bradycardia
Correct Answer: A
Rationale: The correct answer is A: Weak femoral pulses. In pediatric patients, weak femoral pulses are expected due to the normal physiological differences in vascular resistance between upper and lower extremities. This is known as the "femoral pulse lag." Bounding pulses in the lower extremities (choice B) would be abnormal and could indicate a vascular disorder. Cyanosis of the hands and feet (choice C) suggests poor perfusion and oxygenation, which is concerning. Frequent episodes of bradycardia (choice D) could indicate cardiac issues and are not expected in a healthy pediatric patient.
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A charge nurse is teaching a newly licensed nurse about medication Administration. Which of the following information should the charge nurse include?
- A. Avoid preparing medications for more than two clients at one time.
- B. Inform clients about the action of the medication Prior to administration.
- C. Read medication labels at least two times prior to administration.
- D. Complete an incident report if a client vomits after taking a medication.
Correct Answer: C
Rationale: The correct answer is C: Read medication labels at least two times prior to administration. This is crucial to ensure accurate medication administration and prevent medication errors. Reading labels twice helps in verifying the right medication, dose, route, and time. It is a standard safety practice in medication administration. Option A is incorrect as there is no specific rule about preparing medications for multiple clients. Option B is important but not as critical as double-checking the medication labels. Option D is important in certain situations but not directly related to medication administration technique.
A nurse is planning care for a school-age child who is 4 hr postoperative following perforated appendicitis. Which of the following actions should the nurse include in the plan of care?
- A. Offer small amounts of clear liquids 6 hr following surgery
- B. Administer analgesics on a scheduled basis for the first 24 hr
- C. Give cromolyn nebulized solution every 8 hr
- D. Apply a warm compress to the operative site every 4 hr
Correct Answer: B
Rationale: The correct answer is B: Administer analgesics on a scheduled basis for the first 24 hr. Postoperative pain management is crucial for the comfort and well-being of the child. Scheduled analgesics help maintain a consistent level of pain relief, preventing peaks and valleys in pain intensity. This approach is especially important in the initial 24 hours following surgery when pain is typically more intense. Offering small amounts of clear liquids 6 hours post-surgery (Choice A) may not be appropriate as the child may still be recovering from anesthesia and at risk of nausea or vomiting. Giving cromolyn nebulized solution every 8 hours (Choice C) is not indicated for postoperative pain management. Applying a warm compress to the operative site every 4 hours (Choice D) may provide some comfort but does not address the underlying need for analgesia.
A nurse is caring for a child who has cystic fibrosis and requires posterior drainage.
Which action should the nurse take?
- A. Perform the procedure prior to meals.
- B. Perform chest physiotherapy immediately after feeding.
- C. Place the child in a supine position for the procedure.
- D. Limit fluid intake before the procedure.
Correct Answer: A
Rationale: The correct answer is A: Perform the procedure prior to meals. This is because performing the procedure before meals helps prevent potential complications such as aspiration during feeding. By emptying the stomach before meals, the risk of regurgitation and aspiration is reduced. Choices B, C, and D are incorrect because chest physiotherapy immediately after feeding can increase the risk of aspiration, placing the child in a supine position can also increase the risk of aspiration, and limiting fluid intake before the procedure may lead to dehydration and is not necessary for this specific procedure.
A nurse in an antepartum unit is caring for a client.
Nurses' Notes
2000:
Client is 38-year-old, G4 P3 at 38 weeks of gestation. Presents for evaluation of labor and
spontaneous rupture of membranes (SROM). Client states, "My water broke a couple of hours
ago and is a greenish color," Client also reports contractions began about 4 hr. ago and have
become consistently stronger and closer together.
Electronic fetal monitor applied. Small amount of thin green fluid noted on perineal pad.
Contraction palpated, lasted 40 seconds, moderate in intensity. Fetal heart rate (FHR) 165/min.
Vaginal examination performed: cervix 4 cm dilated, 70% effaced, 0 station, vertex presentation.
Client reports a history of chronic hypertension that has been well-controlled during this
pregnancy. Also states was diagnosed with gestational diabetes at 28 weeks of gestation.
2020:
Contractions occurring every 4 to 5 min, lasting 40 to 60 seconds. Small amount of bloody show
noted when changing disposable pad on bed. Client rates contraction pain as a 5 on a scale of 0
to 10, breathing well through contractions., FHR 168/min, minimal variability. Client denies
epigastric pain or visual disturbances. Trace of edema noted to bilateral lower extremities.
2230:
Contractions occurring every 2.5 to 3 minutes, lasting 60 to 70 seconds. Epidural placed by
anesthesiologist. Client rates pain with contractions as a 3 on a scale of 0 to 10. FHR 150/min
with moderate variability. Accelerations present, no decelerations noted.
Vital Signs
2230:
Temperature 38° C (100.4° F)
Heart rate 88/min
Respiratory rate 16/min
Blood pressure 122/80 mm Hg
Oxygen saturation 98% on room air
Select the findings that indicate the interventions have been effective.
- A. Client rates pain with contractions as a 3 on a scale of 0 to 10
- B. Contractions occurring every 2.5 to 3 minutes, lasting 60 to 70 seconds
- C. Accelerations present, no decelerations noted
- D. Heart rate 88/min
- E. Blood pressure 122/80 mm Hg
- F. Temperature 38° C(100.4° F)
Correct Answer: A,C
Rationale: Effective pain relief (client rates pain as 3) and normal FHR patterns indicate successful interventions.
A nurse is assessing a client who has type one diabetes myelitis and was administered insulin lispro 1 hour ago.
Which of the following manifestations indicates that the client might be experiencing hypoglycemia?
- A. Confusion
- B. Increased thirst
- C. Frequent urination
- D. Flushed skin
Correct Answer: A
Rationale: The correct answer is A: Confusion. Hypoglycemia is a condition characterized by low blood sugar levels, leading to symptoms like confusion due to the brain not receiving enough glucose for energy. Increased thirst and frequent urination are more indicative of hyperglycemia (high blood sugar levels). Flushed skin is not a common manifestation of hypoglycemia.