Nokea
Which of the following actions should the nurse take first?
- A. Obtain an x-ray of the child's neck.
- B. Administer intravenous antibiotics.
- C. Initiate droplet precautions.
- D. Place intubation equipment at the bedside.
Correct Answer: D
Rationale: The correct action for the nurse to take first is to place intubation equipment at the bedside (Choice D). This is crucial in case the child's condition deteriorates rapidly and respiratory support is needed. Placing the intubation equipment ensures immediate access to airway management, which takes precedence over other actions. Obtaining an x-ray may provide diagnostic information but is not as urgent as ensuring airway patency. Administering antibiotics and initiating droplet precautions (Choice C) are important but not the immediate priority in this scenario. Therefore, Choice D is the correct first action to ensure the child's safety and optimal care.
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Specify 2 actions the nurse should take to address that condition.
- A. Anticipate a prescription for digoxin.
- B. Elevate the head of the bed to a 45° angle.
- C. Implement contact precautions.
- D. Provide chest physiotherapy and postural drainage.
Correct Answer: A,B
Rationale: The correct answers are A and B. A nurse should anticipate a prescription for digoxin as it is commonly prescribed for heart failure to improve heart function. Elevating the head of the bed to a 45° angle helps reduce the workload on the heart and improve respiratory function. Choice C, implementing contact precautions, is unrelated to addressing the condition. Choice D, providing chest physiotherapy and postural drainage, is not typically indicated for heart failure.
Which of the following immunizations should the nurse plan to administer?
- A. Measles, mumps, and rubella (MMR)
- B. Varicella (VAR)
- C. Rotavirus (RV)
- D. Herpes zoster
- E. Human papillomavirus (HPV4)
Correct Answer: A,B
Rationale: The correct answer is A (MMR) and B (VAR). These immunizations are recommended for certain age groups to prevent measles, mumps, rubella, and varicella. MMR provides protection against three viral infections, while VAR protects against chickenpox. These vaccinations are part of the routine childhood immunization schedule to prevent the spread of these contagious diseases. Rotavirus (C) is given to infants to protect against a common cause of severe diarrhea, while Herpes zoster (D) and Human papillomavirus (E) are not typically administered by nurses in routine practice.
Which of the following statements by the guardian indicates an understanding of the teaching?
- A. I will ensure that my child consumes a high-calorie diet.
- B. I will expect my child to need annual sweat chloride testing.
- C. I will have my child chew the pancrelipase medication before eating.
- D. I will administer dormase alfa every 4 hours for wheezing.
Correct Answer: A
Rationale: The correct answer is A because ensuring the child consumes a high-calorie diet demonstrates an understanding of the teaching regarding managing cystic fibrosis, a condition that requires a high-calorie intake to maintain weight and overall health. This statement aligns with the need for nutritional support in cystic fibrosis management.
Choice B is incorrect because annual sweat chloride testing is not related to dietary management. Choice C is incorrect as chewing pancrelipase medication before eating is not necessary for understanding the teaching about cystic fibrosis. Choice D is incorrect as administering dormase alfa every 4 hours for wheezing does not pertain to dietary requirements in cystic fibrosis.
Which of the following actions is appropriate for the nurse to take?
- A. Obtain written consent from the client.
- B. Request verbal consent from the social worker.
- C. Contact the client's parents to obtain phone consent.
- D. Postpone the testing until the client's parents are present.
Correct Answer: A
Rationale: Correct Answer: A. Obtain written consent from the client.
Rationale: Written consent from the client is essential to ensure autonomy and informed decision-making. It shows respect for the client's rights and allows them to fully understand the procedure or treatment. Verbal consent may not provide a legal record of agreement. Contacting the client's parents without the client's consent may violate confidentiality and autonomy. Postponing testing can delay necessary healthcare. Written consent is the most appropriate choice to uphold ethical and legal standards in healthcare practice.
The nurse should immediately report which of the following findings to the provider?
- A. Rhinorrhea
- B. Pharyngitis
- C. Coughing
- D. Tachypnea
Correct Answer: D
Rationale: The correct answer is D: Tachypnea. Tachypnea, which is rapid breathing, can indicate respiratory distress or an underlying serious condition that requires immediate attention. Reporting this finding promptly is crucial to ensure timely intervention. Rhinorrhea, pharyngitis, and coughing are common symptoms that may not require urgent attention as they can be managed symptomatically. In summary, tachypnea is the most concerning symptom that warrants immediate reporting, while the other choices are less urgent and can be addressed in due course.