Nokea
A nurse is providing teaching about injury prevention to the parents of a toddler.
Which of the following safety measures should the nurse include in the teaching?
- A. Check clothing for loose buttons.
- B. Adjust the water heater temperature to 54° C (129.2° F).
- C. Place screens on all windows.
- D. Provide balloons for play.
Correct Answer: A
Rationale: The correct answer is A: Check clothing for loose buttons. This safety measure is important to prevent choking hazards in children. Loose buttons can easily come off and be swallowed. B is incorrect as the recommended water heater temperature is 49°C (120°F) to prevent scalding. C is irrelevant to the safety of a child's clothing. D is incorrect as balloons pose a choking hazard.
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A nurse is caring for an 8-year-old child who was recently diagnosed with chronic renal failure.
The child's parents ask for information on hemodialysis. Which of the following statements should the nurse make?
- A. Hemodialysis uses your child's abdominal cavity as a membrane to clean their blood.
- B. Hemodialysis uses an electrolyte solution to clean your child's blood.
- C. Hemodialysis uses an artificial membrane outside the body to clean your child's blood.
- D. Hemodialysis slowly filtrates your child's blood continuously.
Correct Answer: C
Rationale: The correct answer is C. Hemodialysis uses an artificial membrane outside the body to clean the child's blood. This is because hemodialysis involves the process of blood being filtered through a machine that uses a synthetic membrane to remove wastes and excess fluids. This process mimics the function of the kidneys in filtering the blood.
Choice A is incorrect because hemodialysis does not use the abdominal cavity as a membrane, it uses an external artificial membrane. Choice B is incorrect as hemodialysis does not involve the use of an electrolyte solution to clean the blood. Choice D is incorrect because hemodialysis is not a continuous filtration process, it is done intermittently during treatment sessions.
A nurse is assessing a school-age child who is receiving cefazolin.
For which of the following adverse effects should the nurse monitor?
- A. Hypotension
- B. Prolonged wound healing
- C. Stevens-Johnson syndrome
- D. Bradypnea
Correct Answer: C
Rationale: The correct answer is C: Stevens-Johnson syndrome. This is a severe adverse reaction characterized by blistering and peeling of the skin, mucous membranes involvement, and flu-like symptoms. It is potentially life-threatening and requires immediate medical intervention. The nurse should monitor for early signs such as rash, fever, and mucosal lesions. Choices A, B, and D are not typically associated with the medication's adverse effects. Hypotension is a common side effect of some medications but not the focus of monitoring for this specific drug. Prolonged wound healing is more related to factors like nutrition and comorbidities. Bradypnea (slow breathing) is not commonly associated with adverse effects of medications but could signify respiratory distress.
A nurse is caring for a group of clients.
Which of the following findings should the nurse report to the provider?
- A. An 18-month-old toddler who has a heart rate of 68/min
- B. A school-age child who has a rectal body temperature of 37.3° C (99.1° F)
- C. An adolescent who has a BP of 132/82 mm Hg
- D. A 3-month-old infant who has a respiratory rate of 30/min
Correct Answer: A
Rationale: The correct answer is A: An 18-month-old toddler who has a heart rate of 68/min. This finding should be reported to the provider because a heart rate of 68/min in an 18-month-old toddler is below the normal range for that age group, which is typically around 100-130/min. This could indicate bradycardia, which may be a sign of an underlying health issue that requires further evaluation and intervention. Reporting this abnormal finding promptly can help the provider assess the toddler's cardiovascular health and determine appropriate management.
The other choices are within normal ranges for their respective age groups:
B: A school-age child with a rectal temperature of 37.3°C (99.1°F) is within the normal range.
C: An adolescent with a blood pressure of 132/82 mm Hg is within the normal range for that age group.
D: A 3-month-old infant with a respiratory rate of 30/min is within the normal
Exhibit 1
Diagnostic Results Cerebrospinal fluid Pressure:
22 cm H2O (less than 20 cm H2O) Color: Cloudy (clear or colorless) Blood: None (none)
Cells
RBC: 0 (0)
WBC: 36 cells/mcL (0 to 30 cells/mcL) Protein: 92 mg/dL (up to 70 mg/dL) Glucose: 36 mg/dL
(50 to 75 mg/dL)
Serum glucose: 64 mg/dL (60 to 100 mg/dL)
A nurse in an emergency department is caring for a 3-month-old infant. Which of the following actions should the nurse take?
- A. Administer ceftriaxone.
- B. Administer pneumococcal conjugate vaccine.
- C. Initiate serum glucose testing every 1 hr.
- D. Initiate neutropenic precautions.
Correct Answer: A
Rationale: The correct answer is A: Administer ceftriaxone. In infants, ceftriaxone is commonly used for treating bacterial infections due to its broad-spectrum coverage. It is important to initiate prompt treatment in infants to prevent complications. Administering a pneumococcal conjugate vaccine (choice B) is important for prevention but not an immediate action in this scenario. Initiating serum glucose testing every 1 hr (choice C) is not necessary unless there are specific indications, as it may cause unnecessary stress to the infant. Neutropenic precautions (choice D) are not relevant in this case as there is no indication of neutropenia.
A nurse in a family practice clinic is assessing a preschool-age child who recently experienced the death of a sibling.
Which of the following reactions is an age-appropriate response to death?
- A. The child views the sibling's death as permanent.
- B. The child is curious about what happened to the sibling's body.
- C. The child can give a logical explanation for the sibling's death.
- D. The child feels responsible for the sibling's death.
Correct Answer: B
Rationale: The correct answer is B because it reflects a common and age-appropriate response to death in children. Curiosity about what happened to the body is natural as children try to make sense of the concept of death. It shows a child's attempt to understand the physical aspect of death without fully grasping its emotional implications. Choices A, C, and D are incorrect. A is incorrect because children often struggle with understanding death as permanent. C is incorrect because logical explanations for death usually come later in development. D is incorrect because children typically do not feel responsible for a sibling's death at a young age.