Nokea
Which of the following would be the best activity for the nurse to include in the plan of care for an infant experiencing severe diarrhea?
- A. Monitoring the total 8-hour formula intake.
- B. Weighing the infant each day.
- C. Checking the anterior fontanel every shift.
- D. Monitoring abdominal skin turgor every shift.
Correct Answer: B
Rationale: Daily weights provide an accurate measure of fluid loss in diarrhea.
You may also like to solve these questions
A nasogastric tube is ordered to be inserted for a child with severe head trauma. Diagnostic testing reveals that the child has a basilar skull fracture. What should the nurse do next?
- A. Ask for the order to be changed to oral gastric tube.
- B. Attempt to place the tube into the duodenum.
- C. Test the gastric aspirate for blood.
- D. Use extra lubrication when inserting the nasogastric tube.
Correct Answer: A
Rationale: Basilar skull fractures contraindicate NG tube insertion due to the risk of cranial penetration; an oral gastric tube is safer.
The nurse is assisting with conscious sedation for a 6-year-old undergoing a bone marrow biopsy. The nurse's most important responsibility during the procedure is to:
- A. Administer the topical anesthetic.
- B. Keep the parents informed.
- C. Monitor the client.
- D. Record the procedure.
Correct Answer: C
Rationale: Monitoring the child during conscious sedation ensures safety, detecting respiratory or cardiovascular changes promptly.
An adolescent with chronic renal failure is scheduled to go home with a peritoneal dialysis catheter in place. When developing the discharge teaching plan for the client and family focusing on psychosocial needs, which of the following areas should be a top priority to include?
- A. Advantages of limiting social activities and contacts for the first few months.
- B. Not disclosing information about the peritoneal dialysis to people outside the family.
- C. Possible effect on body image of the presence of an abdominal catheter.
- D. Importance of relying on parents to do the dialysis and dressing changes.
Correct Answer: C
Rationale: Body image concerns are significant.
Which development is necessary for toilet training readiness for a 2-year-old? Select all that apply.
- A. Adequate neuromuscular development for sphincter control.
- B. Appropriate chronological age.
- C. Ability to communicate the need to use the toilet.
- D. Desire to please the parents.
- E. Ability to play with other 2-year-olds.
Correct Answer: A,C,D
Rationale: Neuromuscular control, communication, and motivation are key for toilet training readiness.
Which of the following questions should the nurse ask first when obtaining a history from the mother of a 10-year-old child with a fever, complaints of not feeling well, and swelling around the eyes?
- A. Has the child had a sore throat recently?
- B. Is the child playing with friends as usual?
- C. Does the child urinate as much as usual?
- D. Is the urine pale in color?
Correct Answer: A
Rationale: Sore throat could indicate streptococcal infection.