Nokea
Which intervention is best to prevent complications associated with traction and immobility?
- A. Offer the child fluids on a frequent basis.
- B. Assist the child to select low-fiber foods.
- C. Assist the child to select low-fiber foods daily.
- D. Reposition the child onto the side every 2 hours.
Correct Answer: A
Rationale: Frequent fluid intake prevents urinary stasis and constipation, common complications of immobility in traction, supporting hydration and kidney function.
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The nurse is administering surfactant via ET tube to a 48-hour-old preterm infant with respiratory distress syndrome (RDS). The father asks the nurse how this treatment will help his baby. The nurse should explain that the preterm infant is unable to produce adequate amounts of surfactant and that giving it to his baby will have what effect?
- A. Increase PaCO2 levels in the bloodstream
- B. Prevent collapse of the alveoli
- C. Decrease PaO2 levels in the bloodstream
- D. Prevent pleural effusion
Correct Answer: B
Rationale: Surfactant prevents alveolar collapse in RDS improving gas exchange decreasing PaCO2 and increasing PaO2. Pleural effusion is unrelated.
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 clinical manifestation of the client's full-thickness burns would the nurse detect during an assessment?
- A. Moderate level of pain due to exposed nerve endings
- B. Eschar formation throughout the area of the burn
- C. The appearance of blister formation throughout the area of the burn
- D. Noted tissue destruction extending to the subcutaneous layer
Correct Answer: D
Rationale: Full-thickness burns involve destruction of all skin layers, including the subcutaneous layer, resulting in a leathery or charred appearance. Pain is minimal due to nerve destruction, and blisters are characteristic of partial-thickness burns.
Which finding by the nurse strongly indicates that a child is experiencing hypokalemia?
- A. Full, bounding pulses
- B. Muscle weakness
- C. Elevated blood pressure
- D. Hyperactive bowel sounds
Correct Answer: B
Rationale: Hypokalemia causes muscle weakness due to impaired muscle contraction, a key manifestation resulting from low potassium levels affecting neuromuscular function.
A breastfeeding mother is being discharged with her 2-day-old,full-term newborn. The nurse recognizes that the mother understands how to determine if her newborn is getting enough breast milk when making which statement?
- A. “He should have at least three wet diapers tomorrow.”
- B. “He should have one stool per day during the next week.”
- C. “At his 1-week checkup,he should weigh an additional 8 ounces.”
- D. “He should nurse for 5 minutes on each breast to get enough milk.”
Correct Answer: A
Rationale: A 3-day-old should have at least three wet diapers indicating adequate intake. Breastfed infants stool 3–10 times daily lose 5–10% birth weight initially and nurse 10–20 minutes per breast.