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Which of the following breathing rates should the nurse use when performing rescue breathing during cardiopulmonary resuscitation for a 5-year-old?
- A. 10 breaths/minute.
- B. 12 breaths/minute.
- C. 15 breaths/minute.
- D. 20 breaths/minute.
Correct Answer: B
Rationale: For a 5-year-old, the recommended rescue breathing rate during CPR is 12 to 20 breaths per minute, with 12 breaths/minute being appropriate to avoid hyperventilation.
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Assessment of a school-age child with Guillain-Barré syndrome reveals absent gag and cough reflexes. Which of the following nursing diagnoses should receive the highest priority during the acute phase?
- A. Risk for infection due to altered immune system.
- B. Ineffective breathing pattern related to neuromuscular impairment.
- C. Impaired swallowing related to neuromuscular impairment.
- D. Total urinary incontinence related to fluid losses.
Correct Answer: B
Rationale: Absent gag and cough reflexes increase the risk of respiratory compromise, making ineffective breathing pattern the highest priority.
The parent of a 9-month-old infant is concerned that the infant's front soft spot is still open. The nurse should tell the parent:
- A. I will measure your baby's head to see if it is a normal size.
- B. Your infant will need to be referred for more testing.
- C. You should contact your physician immediately.
- D. It is normal because this soft spot usually closes between 12 and 18 months.
Correct Answer: D
Rationale: The anterior fontanelle typically closes between 12-18 months, so this is normal.
A 10-year-old has 5 lb of Buck's extension traction on his left leg. The nurse should assess the child for which of the following? Select all that apply.
- A. Dryness of the skin, by removing the foam wraps and boot.
- B. Alignment of the shoulder, hips, and knees.
- C. Frayed rope near pulleys.
- D. Correct amount of traction weight on fracture.
- E. Pressure on the coccyx.
Correct Answer: B,C,D,E
Rationale: The nurse should check alignment, rope condition, weight accuracy, and pressure points to ensure effective and safe traction.
After teaching the parents about the cause of ringworm of the scalp (tinea capitis), which of the following, if stated by the father, indicates successful teaching?
- A. It results from overexposure to the sun.
- B. It's caused by infestation with a mite.
- C. It's a fungal infection of the scalp.
- D. It's an allergic reaction.
Correct Answer: C
Rationale: Tinea capitis is caused by a fungal infection, not mites, sun exposure, or allergies.
Two months after an adolescent's thoracic spinal cord injury, he complains of a pounding headache. The nurse notes that the client's arms and face are flushed and he is diaphoretic. What should the nurse do next?
- A. Check the patency of the urinary catheter.
- B. Lower the adolescent's head below his knees.
- C. Place the adolescent flat on his back.
- D. Prepare to administer epinephrine subcutaneously.
Correct Answer: A
Rationale: These symptoms suggest autonomic dysreflexia, often triggered by bladder distension; checking the catheter is the first step.