Nokea
Which of the following is a priority for the nurse to assess when testing the child's urine?
- A. Blood in the urine
- B. Bilirubin in the urine
- C. Ketones in the urine
- D. White blood cells in the urine
Correct Answer: C
Rationale: In DKA, assessing for ketones in the urine is a priority, as ketonuria confirms the presence of ketones, a hallmark of DKA resulting from fat metabolism due to insulin deficiency.
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Which medication instruction provided by the nurse is most accurate?
- A. Taking your acyclovir as prescribed will prevent the recurrence of lesions.
- B. Your sex partners also need to be treated for 10 days with oral acyclovir.
- C. Use a glove to apply topical acyclovir.
- D. Take the oral acyclovir even when the disease is in remission.
Correct Answer: C
Rationale: Using a glove to apply topical acyclovir prevents self-contamination and virus spread, making it an accurate and safe instruction.
While preparing parents of a 2-day-old,bottle-feeding newborn for discharge the nurse recognizes the parents’ need for additional teaching about formula feeding. Which statement prompted the nurse’s conclusion?
- A. “We plan to clean our baby’s bottles in the dishwasher.”
- B. “Placing the formula in a bowl of warm water will warm it.”
- C. “We will put the bottle of unfinished formula in the refrigerator.”
- D. “Using our city tap water to mix the powdered formula is safe.”
Correct Answer: C
Rationale: Unfinished formula mixed with saliva should be discarded due to bacterial growth risk. Dishwasher cleaning warming in water and municipal tap water use are safe.
During early postburn care of the child, it is essential for the nurse to closely monitor which of the following?
- A. Unburned skin
- B. Bowel elimination
- C. I.V. fluid therapy
- D. Pupillary response to light
Correct Answer: C
Rationale: I.V. fluid therapy is critical in the early postburn phase to prevent hypovolemic shock and maintain organ perfusion. Close monitoring ensures adequate resuscitation and prevents complications like over- or under-hydration.
Which statement by the nurse is most therapeutic in addressing the teen's behavior?
- A. There's nothing to be scared of. This won't hurt.
- B. The stitches are strong. They won't come out.
- C. I know you're scared, but you must be brave.
- D. Let's do this later, when you're better prepared.
Correct Answer: C
Rationale: Acknowledging the teen's fear and encouraging bravery validates their emotions while gently motivating them to proceed with ambulation, fostering trust and cooperation.
Which finding documented by the nurse is most indicative of the presence of a Curling's ulcer in the burned child?
- A. Absence of bowel sounds
- B. A positive hemoccult test
- C. An elevated hematocrit
- D. A distended abdomen
Correct Answer: B
Rationale: A positive hemoccult test indicates gastrointestinal bleeding, characteristic of a Curling's ulcer, a stress ulcer common in burn patients due to physiological stress and reduced mucosal protection.