Nokea
Which intervention should the nurse prioritize for an infant with failure to thrive?
- A. Administer IV fluids.
- B. Establish a feeding schedule.
- C. Order a developmental evaluation.
- D. Increase room temperature.
Correct Answer: B
Rationale: A consistent feeding schedule addresses poor intake, promoting weight gain. IV fluids are for acute dehydration, developmental evaluation is secondary, and room temperature is less relevant.
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The nurse begins CPR on a 5-year-old unresponsive client. When the emergency response team arrives, the child continues to have no respiratory effort but has a heart rate of 50 with cyanotic legs. The team should next:
- A. Discontinue compressions but continue administering breaths with a bag-mask device.
- B. Establish an intravenous line with a large bore needle while preparing the defibrillator.
- C. Begin 2-person CPR at a ratio of 2 breaths to 15 compressions.
- D. Begin 2-person CPR at a ratio of 2 breaths to 30 compressions.
Correct Answer: C
Rationale: For a 5-year-old with a heart rate of 50 (bradycardia) and no respiratory effort, 2-person CPR with a ratio of 2 breaths to 15 compressions is appropriate to optimize oxygenation and circulation.
When developing the teaching plan for the parents of a 12-month-old infant with hypospadias and chordee repair, which of the following should the nurse expect to include as most important?
- A. Assisting the child to become familiar with his dressings so he will leave them alone.
- B. Encouraging the child to ambulate as soon as possible by using a favorite push toy.
- C. Forcing fluids to at least 2,500 mL/day by offering his favorite juices.
- D. Preventing the child from disrupting the catheters by using soft restraints.
Correct Answer: D
Rationale: Restraining prevents dislodgment of catheters.
A 14-year-old is being screened for scoliosis. Which of the following statements about scoliosis screening is true?
- A. Teenagers ages 14 to 16 should be screened yearly.
- B. A shirt and shorts are worn for screening.
- C. The girl is assessed standing and bending forward.
- D. The girl should refrain from eating 8 hours before the examination.
Correct Answer: C
Rationale: Assessing the girl standing and bending forward is the standard method to detect spinal asymmetry during scoliosis screening.
Which of the following actions initiated by the parents of an 8-month-old indicates they need further teaching about preventing childhood accidents?
- A. Placing a fire screen in front of the fireplace.
- B. Placing a car seat in a front-seat, front-facing position.
- C. Inspecting toys for loose parts.
- D. Placing toxic substances out of reach or in a locked cabinet.
Correct Answer: B
Rationale: A front-seat, front-facing car seat is unsafe for an 8-month-old; rear-facing in the back seat is recommended.
The mother of an 8-year-old with diabetes tells the nurse that she does not want the school to know about her daughter's condition. The nurse should reply:
- A. I think that would be a good idea.'
- B. What is it that concerns you about having the school know about your daughter's condition?'
- C. It would be fine not to tell your daughter's friends, but the teacher must know.'
- D. In order to keep your daughter safe, it is necessary for all adults in the school to know her condition.'
Correct Answer: B
Rationale: Exploring concerns builds trust and allows the nurse to address fears while explaining the need for school awareness (e.g., for hypoglycemia management). Other responses dismiss or mandate without dialogue.