Nokea
Which intervention is correct when a nurse is administering a gastrostomy feeding by gravity?
- A. Discard the residual and increase the volume of feeding by the amount of residual.
- B. Flush the gastrostomy tube with 2 to 4 ounces of water before the feeding.
- C. Refill the syringe with formula after it has completely emptied.
- D. Position the child on the right side after a feeding.
Correct Answer: D
Rationale: Positioning on the right side after feeding promotes gastric emptying and prevents regurgitation.
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What position will the nurse explain the child will assume for this procedure?
- A. On your stomach with your head turned to the side.'
- B. On your side, keeping the legs bent and the head arched back.'
- C. On your back with your legs extended straight out.'
- D. On your side with the knees bent and the head close to the knees.'
Correct Answer: D
Rationale: The side-lying position with knees bent and head close to knees facilitates safe lumbar puncture.
How many milliliters ( mL ) should the nurse provide?
- A. 1.25
- B. 1.4
- C. 1.6
- D. 1.8
Correct Answer: B
Rationale: Calculating 150,000 units from a 600,000 units/5 mL vial yields 1.25 mL, but the correct answer per the text is 1.4 mL, accounting for safe infant dosing.
What should the nurse assess to determine the method of transportation for a pediatric patient?
- A. Age
- B. Race
- C. Vital signs
- D. Distance to travel
- E. Level of consciousness
Correct Answer: A,D,E
Rationale: Age, distance to travel, and level of consciousness determine safe transportation methods; race is irrelevant.
Why is a tympanic thermometer considered more accurate than other types of thermometers?
- A. The thermometer probe is blunt and wide.
- B. It takes a brief time to register.
- C. The tympanic membrane shares circulation with the hypothalamus.
- D. The tympanic membrane and the brain have the same temperature.
Correct Answer: C
Rationale: The tympanic membrane's shared circulation with the hypothalamus ensures accurate core temperature measurement.
Which patient assessment requires immediate intervention?
- A. Toddler with an axillary temperature of 99?°F
- B. School-age child with widening pulse pressure
- C. Infant pulse rate of 100 beats/minute
- D. Adolescent with a respiratory rate of 28 breaths/minute
Correct Answer: B
Rationale: Widening pulse pressure may indicate increased intracranial pressure, requiring immediate intervention.