Nokea
Which nursing interventions are essential to restore the child's fluid and electrolyte balance during the emergent phase of burn care and treatment? Select all that apply.
- A. Initiate the administration of I.V. fluids.
- B. Track the child's vital signs.
- C. Give the child sips of water.
- D. Encourage the child to consume protein-rich feedings.
- E. Monitor the child's urine output.
- F. Assemble equipment for a small-gauge venous catheter.
Correct Answer: A,B,E,F
Rationale: During the emergent phase, I.V. fluids restore fluid and electrolyte balance due to massive losses. Monitoring vital signs and urine output assesses fluid status, and preparing venous access ensures timely administration. Oral fluids and protein-rich feedings are inappropriate due to gastrointestinal dysfunction.
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Which dietary recommendation should the nurse provide to the parents of a child with iron deficiency anemia?
- A. Increase intake of red meat and leafy greens.
- B. Offer more dairy products like milk and cheese.
- C. Provide high-sugar snacks to boost energy.
- D. Limit consumption of whole grains.
Correct Answer: A
Rationale: Red meat and leafy greens are rich in iron, which is essential for correcting iron deficiency anemia by boosting hemoglobin production.
A 30 years old G5P4 is admitted in labor room with H/O 32 weeks gestation,mild vaginal bleeding and abdominal pain. O/E her blood pressure 140/100 mm Hg abdomen is tense tender and hard. Fetal heart sounds are not audible. What is the most likely diagnosis:
- A. Placenta praevia.
- B. Abruptio placenta.
- C. Preterm labour.
- D. Urinary tract infection.
- E. Vasa praevia.
Correct Answer: B
Rationale: Abruptio placenta presents with vaginal bleeding abdominal pain a tense uterus and fetal distress (absent heart sounds) often with hypertension. Placenta previa typically causes painless bleeding and other options do not match the clinical picture.
The nurse is caring for a 30-year-old,single female who delivered a term newborn. What is the best way for the nurse to assess the impact of the newborn on the client’s lifestyle?
- A. Observe how the client interacts with her hospital visitors.
- B. Review the prenatal record for clues about the client’s lifestyle.
- C. Ask the client what plans she has made for newborn care at home.
- D. Observe the relationship between the client and her newborn’s father.
Correct Answer: C
Rationale: Open-ended questions about newborn care plans encourage sharing of lifestyle adjustments especially for single parents. Visitors prenatal records or father involvement are less direct.
As the nurse prepares to administer prophylactic eye treatment to prevent gonorrheal conjunctivitis in the full-term newborn,the newborn’s father asks if it is really necessary to put something into his baby’s eyes. Which statement should be the basis for the nurse’s response?
- A. It is the law in the United States that newborns receive this prophylactic treatment.
- B. This treatment is recommended but may be omitted at the parent’s verbal request.
- C. The antibiotic used for the treatment can be given orally at the parent’s request.
- D. The eye prophylaxis can be given anytime up until the infant is 1 year old.
Correct Answer: A
Rationale: Currently every U.S. state requires that newborns receive prophylactic eye treatment against gonorrheal conjunctivitis. Refusal requires formal documentation the antibiotic is topical only and prophylaxis must be given within 1 hour of birth.
Which of the following is the priority nursing action if the child shows symptoms of hypoglycemic reaction?
- A. Give the child orange juice or milk to drink.
- B. Give the child 10% glucose I.V.
- C. Notify the physician immediately.
- D. Administer a second dose of insulin.
Correct Answer: A
Rationale: For hypoglycemia, the priority is to rapidly raise blood glucose. Giving orange juice or milk provides quick-acting carbohydrates, the first-line treatment for conscious patients with mild to moderate hypoglycemia.