Nokea
Which of the following assessments should be the priority for an infant who has had surgery to correct an intussusception and is now at risk for development of a paralytic ileus postoperatively?
- A. Measurement of urine specific gravity.
- B. Auscultation of bowel sounds.
- C. Inspection of the first stool passed.
- D. Measurement of gastric output.
Correct Answer: B
Rationale: Auscultating bowel sounds monitors for paralytic ileus, a critical postoperative complication.
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A 10-year-old has just spilled hot liquid on his arm, and a 4-inch area on his forearm is severely burned. His mother calls the emergency department. What should the nurse advise the mother to do?
- A. To the child warm.
- B. Cover the burned area with an antibiotic cream.
- C. Apply cool water to the burned area.
- D. Call 911 to transport the child to the hospital.
Correct Answer: C
Rationale: Applying cool (not cold) water for 10-15 minutes reduces burn depth and pain. Keeping the child warm is secondary, antibiotic cream is not immediate, and 911 is unnecessary for a localized burn unless systemic symptoms appear.
Initiation of which of the following immunizations is recommended prior to the adolescent entering college?
- A. Diphtheria, tetanus, and acellular pertussis (DTaP).
- B. Varicella.
- C. Meningococcal.
- D. Pneumococcal conjugate vaccine (PCV).
Correct Answer: C
Rationale: Meningococcal vaccine is recommended before college due to increased risk in dormitories.
A nurse is teaching a child with a food allergy about safe eating. Which instruction is most important?
- A. Eat only home-cooked meals.
- B. Read food labels carefully.
- C. Avoid all fruits.
- D. Use herbal supplements.
Correct Answer: B
Rationale: Reading food labels prevents accidental allergen exposure. Home cooking helps but isn't always feasible, fruits are safe unless allergenic, and supplements are irrelevant.
A nurse is counseling parents of an obese child. Which lifestyle change should be emphasized?
- A. Eliminate all carbohydrates.
- B. Increase physical activity.
- C. Restrict meals to twice daily.
- D. Use meal replacement shakes.
Correct Answer: B
Rationale: Increased physical activity promotes weight control and health. Eliminating carbohydrates, restricting meals, or using shakes are not sustainable or appropriate for children.
While assessing a 3-year-old child who has had an injury to the leg, has pain, and refuses to walk, the nurse notes that the child's left thigh is swollen. What should the nurse do next?
- A. Assess the neurologic status of the toes.
- B. Determine the circulatory status of the upper thigh.
- C. Obtain the child's vital signs.
- D. Notify the physician immediately.
Correct Answer: D
Rationale: Swelling, pain, and refusal to walk suggest a serious injury, possibly a fracture, requiring immediate physician notification.