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Which of the following outcome criteria would the nurse develop for a child with cystic fibrosis who has a nursing diagnosis of Ineffective airway clearance related to increased pulmonary secretions and inability to expectorate?
- A. Respiratory rate and rhythm within expected range.
- B. Absence of chills and fever.
- C. Ability to engage in age-related activities.
- D. Ability to tolerate usual diet without vomiting.
Correct Answer: A
Rationale: A respiratory rate and rhythm within the expected range is an appropriate outcome for ineffective airway clearance, indicating improved mucus clearance and respiratory function.
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A child is admitted to the pediatric unit with the diagnosis of severe gastroenteritis. To prevent spread of the disease the nurse should?
- A. Institute standard precautions.
- B. Place the child in a semiprivate room.
- C. Serve meals with eating utensils that can be sterilized.
- D. Single-bag all linens.
Correct Answer: A
Rationale: Standard precautions prevent the spread of infectious gastroenteritis.
The nurse teaches the parents of an infant with developmental dysplasia of the hip how to handle their child in a Pavlik harness. Which of the following is most appropriate?
- A. Fitting the diaper under the straps.
- B. Leaving the harness off while the infant sleeps.
- C. Checking for skin redness under straps every other day.
- D. Putting powder on the skin under the straps every day.
Correct Answer: A
Rationale: Fitting the diaper under the straps ensures hygiene without disrupting the harness's corrective positioning.
The parents of a child with a tracheoesophageal fistula express feelings of guilt about their baby's anomaly. Which of the following approaches by the nurse would best support the parents?
- A. Helping the parents accept their feelings as a normal reaction.
- B. Explaining that the parents did nothing to cause the newborn's defect.
- C. Encouraging the parents to concentrate on planning their baby's care.
- D. Urging the parents to visit their newborn as often as possible.
Correct Answer: A
Rationale: Acknowledging and normalizing the parents' guilt helps them process emotions and supports coping.
An adolescent complains of chest pain and goes to the school nurse. The nurse determines that the teenager has a history of asthma but has had no problems for years. Which of the following should the nurse do next?
- A. Call the adolescent's parent.
- B. Have the adolescent lie down for 30 minutes.
- C. Obtain a peak flow reading.
- D. Give two puffs of a short-acting bronchodilator.
Correct Answer: C
Rationale: Obtaining a peak flow reading is the next step to objectively assess the adolescent's respiratory status, given the history of asthma and new chest pain, which could indicate an asthma exacerbation.
During physical assessment of a 4-month-old infant with Hirschsprung's disease, the nurse should most likely note which of the following?
- A. Scaphoid-shaped abdomen.
- B. Weight less than expected for height and age.
- C. Cyanosis of the fingers and toes.
- D. Hyperactive deep tendon reflexes.
Correct Answer: B
Rationale: Hirschsprung's disease can lead to poor weight gain due to bowel obstruction.