Nokea
Which food would the nurse recommend to include in the child's diet?
- A. Cooked vegetables
- B. Pretzels
- C. Whole-grain cereal
- D. Yogurt
Correct Answer: C
Rationale: Whole-grain cereal, a high-roughage food, helps alleviate constipation by promoting bowel movements.
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What does the nurse expect this child to receive following gastric lavage?
- A. Activated charcoal
- B. N-Acetylcysteine
- C. Vitamin K
- D. Syrup of ipecac
Correct Answer: B
Rationale: N-Acetylcysteine is the antidote for acetaminophen poisoning, administered after gastric lavage.
A child is brought into the ED with suspected appendicitis.
- A. Left lower quadrant pain
- B. Guarding
- C. Rebound tenderness
- D. Decreased C-reactive protein
- E. Pain on lifting thigh when supine
Correct Answer: B,C,E
Rationale: Guarding, rebound tenderness, and pain on thigh lifting are signs of appendicitis; pain is in the right lower quadrant, and C-reactive protein is elevated.
Which is the most appropriate intervention for a 3-month-old infant who has gastroesophageal reflux?
- A. Position the infant in the crib on his or her abdomen, with the head elevated.
- B. Administer medication as ordered to stimulate the pyloric sphincter.
- C. Give thin rice cereal with formula before feeding solid foods.
- D. Place the infant in an infant seat after feedings.
Correct Answer: A
Rationale: Prone positioning with the head elevated reduces intraabdominal pressure and helps manage gastroesophageal reflux.
Which assessment would the nurse report to the physician immediately?
- A. 2-month-old with a urine output of 150 mL in 24 hours
- B. 3-year-old with a urine output of 650 mL in 24 hours
- C. 8-year-old with a urine output of over 1000 mL in 24 hours
- D. 14-year-old with a urine output of 800 mL in 24 hours
Correct Answer: A
Rationale: A 2-month-old's urine output of 150 mL/24 hours is significantly below the expected 400-500 mL, indicating possible dehydration.
Which assessment finding indicates ineffectiveness of treatment?
- A. Weight loss of 4 ounces
- B. Dry mucous membranes
- C. Decreased skin turgor
- D. Depressed fontanelle
Correct Answer: A
Rationale: Weight loss in an infant with gastroenteritis indicates ongoing dehydration, reflecting ineffective treatment.