Nokea
Which of the following findings during a routine wellness checkup best indicates that a child has iron deficiency anemia?
- A. Weight gain and hypertension
- B. Nervousness and diarrhea
- C. Nausea and vomiting
- D. Pallor and listlessness
Correct Answer: D
Rationale: Pallor and listlessness are hallmark signs of iron deficiency anemia due to reduced hemoglobin, leading to decreased oxygen delivery and fatigue.
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Which findings by the nurse best indicate that the child is experiencing diabetic ketoacidosis? Select all that apply.
- A. Blood glucose level of 120 mg/dL
- B. Fruity-smelling breath
- C. Pale-colored face
- D. Excessive perspiration
- E. Deep, rapid breathing
- F. Dry, flushed skin
Correct Answer: B,E,F
Rationale: Diabetic ketoacidosis (DKA) is characterized by hyperglycemia (blood glucose typically >250 mg/dL, so 120 mg/dL is incorrect), fruity-smelling breath due to acetone, deep and rapid breathing (Kussmaul respirations) to compensate for acidosis, and dry, flushed skin due to dehydration.
The nurse is caring for a preterm infant who must be fed via bolus gavage feeding. The infant has a 5 French feeding tube already secured in the left naris. The nurse has aspirated the infant’s stomach contents, noting color, amount, and consistency, and has reinserted the residual amount because it was less than one-fourth the previous feeding. Prioritize the remaining steps that the nurse should take to complete this feeding.
- A. Elevate the syringe 6 to 8 inches over the infant’s head.
- B. Position the infant on the right side.
- C. Uncrimp the tubing and allow the feeding to flow by gravity at a slow rate.
- D. Crimp the feeding tube and pour the specified amount of formula or breast milk into the barrel.
- E. Cap the lavage feeding tube.
Correct Answer: D, A, F, C, E, B, G
Rationale: Sequence: Position infant on right side (D) to reduce aspiration risk connect syringe barrel (A) crimp tube and pour formula (F) elevate syringe (C) uncrimp for gravity flow (E) clear tubing with air (B) cap tube (G).
Which finding best indicates that a school-age child has acute glomerular nephritis?
- A. Periorbital edema
- B. Excessive urination
- C. Increased appetite
- D. Low blood pressure
Correct Answer: A
Rationale: Periorbital edema is a classic sign of acute glomerular nephritis due to fluid retention from impaired glomerular filtration, reflecting reduced sodium and water excretion.
As the nurse prepares to administer prophylactic eye treatment to prevent gonorrheal conjunctivitis in the full-term newborn,the newborn’s father asks if it is really necessary to put something into his baby’s eyes. Which statement should be the basis for the nurse’s response?
- A. It is the law in the United States that newborns receive this prophylactic treatment.
- B. This treatment is recommended but may be omitted at the parent’s verbal request.
- C. The antibiotic used for the treatment can be given orally at the parent’s request.
- D. The eye prophylaxis can be given anytime up until the infant is 1 year old.
Correct Answer: A
Rationale: Currently every U.S. state requires that newborns receive prophylactic eye treatment against gonorrheal conjunctivitis. Refusal requires formal documentation the antibiotic is topical only and prophylaxis must be given within 1 hour of birth.
If the nurse documents all the following data, which finding should be reported immediately?
- A. Refusal to eat
- B. Complaint of nausea
- C. Absent bowel sounds
- D. Temperature of 101°F (38.3°C) orally
Correct Answer: C
Rationale: Absent bowel sounds may indicate peritonitis or bowel obstruction, serious complications of appendicitis requiring immediate reporting to prevent further deterioration.