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Which observation on entering the hospital room lets the nurse know that there is a need for the parents to receive safety education to prevent unintentional injury?
- A. The blanket is not tucked into the mattress.
- B. Diapers and wipes are stacked at the foot of the crib.
- C. The crib side is locked in the up position.
- D. Pillows are stacked on the bedside table.
Correct Answer: B
Rationale: Diapers and wipes at the crib's foot pose a suffocation risk, indicating a need for parental safety education.
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What statement made by the adolescent led the nurse to determine she understood the instructions?
- A. I should wash my perineum with soap and water, then begin to urinate.'
- B. I clean the perineum from front to back with an antiseptic wipe before I urinate.'
- C. I'll collect the first stream of urine in a sterile container.'
- D. I will discard the first void and collect a freshly voided specimen 30 minutes later.'
Correct Answer: B
Rationale: Cleaning the perineum from front to back with an antiseptic wipe ensures a clean-catch urine specimen.
The order reads, 'Give ampicillin oral suspension 400 mg PO every day.' The vial reads, 'Ampicillin 125 mg/5 mL.' The nurse will give a dose of __ mL.
Correct Answer: 16
Rationale: Calculating 400 mg from 125 mg/5 mL yields 16 mL as the correct daily dose.
After instilling nose drops, the nurse will keep the infant in the head down position for at least __ seconds.
Correct Answer: 30
Rationale: Retaining the head-down position for 30 seconds allows nose drops to penetrate deeply into the nostril.
What would be the best example provided by the nurse?
- A. Red meat
- B. Green, leafy vegetables
- C. Acidic fruit juices
- D. Egg yolks
Correct Answer: D
Rationale: Egg yolks reduce iron absorption in the digestive tract and should be limited when taking iron supplements.
Which actions will the nurse implement?
- A. Assess rectal temperature every 4 hours.
- B. Administer acetaminophen as ordered.
- C. Assess skin turgor.
- D. Restrict fluids.
- E. Assess level of consciousness.
Correct Answer: B,C,E
Rationale: Administering acetaminophen, assessing skin turgor, and monitoring consciousness address fever and dehydration risks; rectal temperatures are avoided in pediatrics.