Nokea
A nurse is planning care for a toddler who has epiglottitis. Which of the following interventions should the nurse include?
- A. Offer a high-calorie, high-protein diet.
- B. Administer pancreatic enzymes with meals.
- C. Initiate droplet precautions.
- D. Carefully suction the child's oropharynx to remove secretions.
Correct Answer: C
Rationale: The correct answer is C: Initiate droplet precautions. Epiglottitis is a serious condition that involves inflammation of the epiglottis, which can lead to airway obstruction. Droplet precautions are necessary to prevent the spread of infection, as epiglottitis is usually caused by a bacterial infection. Offering a high-calorie, high-protein diet (choice A) is not the priority in the acute phase of epiglottitis. Administering pancreatic enzymes with meals (choice B) is unrelated to the care of a toddler with epiglottitis. Carefully suctioning the child's oropharynx to remove secretions (choice D) can potentially worsen the condition by triggering a gag reflex and causing further airway obstruction.
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A nurse is caring for a group of toddlers receiving digoxin therapy. For which of the following clients should the nurse plan to hold the dose of digoxin?
- A. A toddler who has an apical pulse of 100 bpm
- B. A toddler who has a potassium level of 4.0 mEq/L (3.6 to 5.2 mEq/L)
- C. A toddler who has a digoxin level of 1.2 ng/mL (0.8 to 2.0 ng/mL)
- D. A toddler who has vomited 2 times in the last hour
Correct Answer: D
Rationale: The correct answer is D because vomiting can lead to decreased absorption of digoxin, potentially resulting in subtherapeutic levels. Holding the dose in this situation prevents giving an ineffective dose. Option A is incorrect because an apical pulse of 100 bpm is within the normal range for toddlers on digoxin. Option B is incorrect because a potassium level of 4.0 mEq/L is also within the normal range. Option C is incorrect because a digoxin level of 1.2 ng/mL falls within the therapeutic range.
A nurse in a clinic is planning care for a child who has ADHD and is taking atomoxetine. Which of the following laboratory values should the nurse monitor?
- A. Liver function tests
- B. Kidney function tests
- C. Hemoglobin and hematocrit
- D. Serum sodium and potassium
Correct Answer: A
Rationale: The correct answer is A: Liver function tests. Atomoxetine, used for ADHD, can potentially cause liver toxicity. Monitoring liver function tests helps detect any signs of liver damage early on. Choice B, kidney function tests, is not as relevant as atomoxetine primarily affects the liver. Choice C, hemoglobin and hematocrit, is not directly impacted by atomoxetine. Choice D, serum sodium and potassium, is not typically affected by atomoxetine use.
A nurse is assessing a 5-year-old child who has diabetes insipidus and is receiving desmopressin. Which of the following findings should the nurse identify as an indication that the medication is effective?
- A. Heart rate 140/min
- B. Capillary refill 3 seconds
- C. Absence of hypoglycemic episodes
- D. Cessation of nocturnal enuresis
Correct Answer: D
Rationale: The correct answer is D: Cessation of nocturnal enuresis. Desmopressin is a medication used to treat diabetes insipidus by decreasing urine output. Nocturnal enuresis is a common symptom of diabetes insipidus due to excessive urine production at night. Therefore, the cessation of nocturnal enuresis indicates that the medication is effectively reducing urine output in the child. Choices A, B, and C are unrelated to the effectiveness of desmopressin in treating diabetes insipidus. Choice A, heart rate of 140/min, is not a specific indicator of desmopressin effectiveness. Choice B, capillary refill of 3 seconds, is a measure of peripheral perfusion and not directly related to diabetes insipidus. Choice C, absence of hypoglycemic episodes, is more relevant to diabetes mellitus and not diabetes insipidus.
A nurse is caring for a 1-year-old child who has been hospitalized. Which of the following items in the child's room is a common source of health care-associated infections?
- A. Disposable diapers
- B. Bedside commode
- C. Protective plastic gowns
- D. Unopened bottles of formula
Correct Answer: B
Rationale: The correct answer is B: Bedside commode. This item can harbor bacteria and pathogens if not properly cleaned and sanitized, leading to healthcare-associated infections. Disposable diapers (A) are single-use and unlikely to cause infections. Protective plastic gowns (C) are meant to prevent infections. Unopened bottles of formula (D) are sterile and not a common source of infections.
A nurse is caring for a school-age child who has sickle cell anemia and is in vaso-occlusive crisis. Which of the following actions should the nurse take?
- A. Apply cold compresses to the affected areas.
- B. Prepare for a transfusion of platelets.
- C. Promote active range of motion exercises.
- D. Increase oral fluid intake.
Correct Answer: D
Rationale: The correct answer is D: Increase oral fluid intake. During a vaso-occlusive crisis in sickle cell anemia, there is a blockage of blood flow leading to tissue ischemia and pain. Increasing oral fluid intake helps to hydrate the child and improve blood flow, potentially reducing the severity of the crisis. Cold compresses (A) can worsen vasoconstriction, platelet transfusion (B) is not indicated for vaso-occlusive crisis, and active range of motion exercises (C) can exacerbate pain and further compromise blood flow. Increasing fluid intake is the most appropriate intervention to help manage the crisis.