Nokea
Which of the following should the nurse expect to observe in an infant with intussusception before surgical intervention?
- A. Fever and lethargy.
- B. Currant jelly stools.
- C. Frequent loose stools.
- D. Increased appetite.
Correct Answer: B
Rationale: Currant jelly stools are a classic sign of intussusception due to mucosal bleeding.
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While performing daily peritoneal dialysis and catheter exit site care with the mother of a child with chronic renal failure, which of the following would be an important step to emphasize to the mother?
- A. Applying an occlusive dressing after cleaning the site.
- B. Changing the dressing when the peritoneal space is dry.
- C. Examining the site for signs of infection while cleaning the area.
- D. Pulling on the catheter to hold taut while cleaning the skin.
Correct Answer: C
Rationale: Checking for signs of infection is crucial.
The nurse judges that the mother has understood the teaching about care of an infant with colic when the nurse observes the mother doing which of the following?
- A. Holding the infant prone while feeding.
- B. Holding the infant in her lap to burp.
- C. Placing the infant prone after the feeding.
- D. Burping the infant during and after the feeding.
Correct Answer: D
Rationale: Burping during and after feeding reduces air swallowing, easing colic symptoms. Prone positioning during or after feeding increases aspiration risk, and lap burping is less effective.
A 12-year-old with cystic fibrosis is being treated in the hospital for pneumonia. The physician is calling in a telephone order for ampicillin. The nurse should do which of the following? Select all that apply.
- A. Ask the unit clerk to listen on the speaker phone with the nurse and write down the order.
- B. Ask the physician to come to the hospital and write the order.
- C. Repeat the order to the physician.
- D. Ask the physician to confirm that the order is correct as understood by the nurse.
- E. Ask the nursing supervisor to cosign the telephone order as transcribed by the nurse.
Correct Answer: C,D
Rationale: Repeating the order to the physician and asking for confirmation ensures accuracy and safety in transcribing the telephone order for ampicillin.
When teaching the child with scoliosis being treated with a Boston brace about exercises, the nurse explains that the exercises are performed primarily for which of the following purposes?
- A. To decrease back muscle spasms.
- B. To improve the brace's traction effect.
- C. To prevent spinal contractures.
- D. To strengthen the back and abdominal muscles.
Correct Answer: D
Rationale: Exercises for scoliosis in a Boston brace focus on strengthening back and abdominal muscles to support spinal alignment and improve posture.
A toddler diagnosed with nephrotic syndrome has a nursing diagnosis of Excess fluid volume related to fluid accumulation in the tissues. Which measure should the nurse anticipate including in the child's plan of care?
- A. Limiting visitors to 2 to 3 hours a day.
- B. Maintaining strict bed rest.
- C. Testing urine specific gravity every shift.
- D. Weighing the child before breakfast.
Correct Answer: D
Rationale: Daily weights monitor fluid balance.