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Which of the following would alert the nurse to suspect that a child with severe gastroenteritis who has been receiving intravenous therapy for the past several hours may be developing circulatory overload?
- A. A drop in blood pressure.
- B. An increase in temperature.
- C. Auscultation of moist crackles.
- D. Marked increase in urine output.
Correct Answer: C
Rationale: Moist crackles indicate fluid in the lungs, a sign of circulatory overload.
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Because of the risks associated with administration of factor VIII concentrate, the nurse should teach the child's family to recognize and report which of the following?
- A. Yellowing of the skin.
- B. Constipation.
- C. Abdominal distention.
- D. Puffiness around the eyes.
Correct Answer: A
Rationale: Yellowing of the skin (jaundice) may indicate hepatitis, a risk with factor VIII. Other symptoms are less directly related to factor risks.
After teaching the mother of a 2-year-old child with lactose intolerance about which dairy products to include in the child's diet, which of the following if stated by the mother indicates effective teaching?
- A. Ice cream.
- B. Creamed soups.
- C. Pudding.
- D. Cheese.
Correct Answer: D
Rationale: Hard cheeses (e.g., cheddar) are low in lactose and often tolerated. Ice cream, creamed soups, and pudding have high lactose content, causing symptoms.
During a clinic visit, the mother of an infant with hydrocele states that the infant's scrotum is smaller now than when he was born. After teaching the mother about the infant's condition, which of the following statements by the mother indicates that the teaching has been effective?
- A. I guess keeping his bottom up has helped.
- B. Massaging his groin area is working.
- C. It seems like the fluid is being reabsorbed.
- D. Keeping him quiet and in an infant seat has helped.
Correct Answer: C
Rationale: Fluid reabsorption is a natural resolution process.
The nurse is administering gastrostomy feedings to an infant after surgery to correct a tracheoesophageal fistula (TEF). To prevent air from entering the stomach once the syringe barrel is attached to the gastrostomy tube the nurse should:
- A. Unclamp the tube after pouring the complete amount of formula to be administered into the syringe barrel.
- B. Pour all of the formula to be administered into the syringe barrel after opening the clamp.
- C. Maintain a continuous flow of formula down the side of the syringe barrel once the clamp is opened.
- D. Move small amount of formula to enter the stomach before pouring more formula into the syringe barrel.
Correct Answer: D
Rationale: Allowing small amounts of formula to enter before adding more prevents air from being trapped in the tube.
A 9-year-old child with Guillain-Barré syndrome requires mechanical ventilation. Which action should the nurse take?
- A. Maintain the child in a supine position to prevent unnecessary nerve stimulation.
- B. Transfer the child to a bedside chair three times a day to prevent postural hypotension.
- C. Engage the child in vigorous passive range-of-motion exercises to prevent loss of muscle function.
- D. Turn the child slowly and gently from side to side to prevent respiratory complications.
Correct Answer: D
Rationale: Turning the child gently prevents respiratory complications like atelectasis while minimizing discomfort in Guillain-Barré syndrome.