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Which of the following actions should the nurse take to encourage acceptance of the medication?
- A. Provide an ice pop after administering the medication.
- B. Give 4 oz of milk with the medication.
- C. Mix the medication with the child's favorite food.
- D. Dilute the medication with 8 oz of water.
Correct Answer: A
Rationale: The correct answer is A. Providing an ice pop after administering the medication can create a positive association with taking the medication. The cold sensation and flavor can help mask any unpleasant taste, making the child more likely to accept the medication. Choice B might not be effective as milk may interfere with the medication's absorption. Choice C could work if the child does not detect the medication in the food. Choice D is not ideal as diluting the medication may reduce its effectiveness.
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Which of the following findings should indicate to the nurse that treatment has been effective?
- A. Odorless urine
- B. No report of pain with voiding
- C. Urine output 256 mL over 8 hours
- D. Temperature 37.2° C (99° F)
Correct Answer: C
Rationale: The correct answer is C: Urine output 256 mL over 8 hours. This finding indicates effective treatment as it shows adequate kidney function and hydration status. Normal urine output is 30-50 mL/hr, so 256 mL over 8 hours is within the expected range.
A: Odorless urine is a general indicator of hydration but not a definitive sign of treatment effectiveness.
B: No report of pain with voiding is subjective and may not always reflect treatment effectiveness.
D: Temperature within normal range is a good sign, but it does not directly indicate treatment effectiveness related to the urinary system.
Which of the following findings should the nurse expect?
- A. Cyanosis
- B. Weight loss
- C. Bounding peripheral pulses
- D. Dyspnea
- E. Tachycardia
Correct Answer: A,D,E
Rationale: The correct answer is A, D, and E. Cyanosis indicates poor oxygenation, dyspnea signifies difficulty in breathing, and tachycardia suggests an increased heart rate to compensate for decreased oxygen levels. Weight loss and bounding peripheral pulses are not typical findings in a patient with impaired oxygenation. In summary, the nurse should expect cyanosis, dyspnea, and tachycardia as key findings in a patient with compromised oxygenation.
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.
Which of the following findings indicates proper functioning of the child's trigeminal nerve?
- A. The child maintains balance when standing with eyes closed.
- B. The child exhibits a gag reflex when stimulated with a tongue blade.
- C. The child correctly identifies specific scents.
- D. The child has symmetrical jaw strength when biting down.
Correct Answer: D
Rationale: The correct answer is D because symmetrical jaw strength when biting down indicates proper functioning of the trigeminal nerve, which controls the muscles of mastication. Choice A relates to the vestibular system, not the trigeminal nerve. Choice B involves the glossopharyngeal and vagus nerves. Choice C is related to the olfactory nerve.
Which of the following information should the nurse include in the teaching?
- A. Provide for periods of rest.
- B. Increase the child's oxygen flow rate until the child no longer has cyanosis.
- C. Withhold digoxin if the child's pulse is greater than 100/min.
- D. Weigh the child once each month.
Correct Answer: A
Rationale: Correct Answer: A - Provide for periods of rest.
Rationale: It is important for the nurse to include information about providing periods of rest in the teaching because rest is essential for recovery and healing. Rest allows the body to conserve energy, reduce stress, and promote overall well-being. By including this information, the nurse is promoting the child's health and supporting the healing process.
Summary of other choices:
B: Increasing oxygen flow rate until cyanosis resolves can lead to oxygen toxicity and is not a safe or appropriate intervention.
C: Withholding digoxin based solely on pulse rate without considering other factors or consulting the healthcare provider can be dangerous and potentially harmful.
D: Weighing the child once a month is important for monitoring growth and nutrition, but it is not directly related to the immediate care and teaching needed in this scenario.