Nokea
Which patient assessment requires immediate intervention?
- A. Toddler with an axillary temperature of 99?°F
- B. School-age child with widening pulse pressure
- C. Infant pulse rate of 100 beats/minute
- D. Adolescent with a respiratory rate of 28 breaths/minute
Correct Answer: B
Rationale: Widening pulse pressure may indicate increased intracranial pressure, requiring immediate intervention.
You may also like to solve these questions
What is the nurse's most effective response?
- A. No. It is over before you know it.'
- B. Yes. It will sting a little.'
- C. No. Would you like to see the syringe?'
- D. Yes. Your mom and I are going to hold you to help you be still.'
Correct Answer: B
Rationale: A truthful response about a slight sting builds trust and prepares the child for the IM injection.
How would the nurse record the infant's urine output?
- A. 47 mL
- B. 44.5 mL
- C. 43.5 mL
- D. 40.5 mL
Correct Answer: B
Rationale: Subtracting the dry diaper weight (2.5 g) from the wet diaper weight (47 g) yields 44.5 mL of urine output.
Which intervention will the nurse implement when suctioning a tracheostomy?
- A. Suction for two to three breaths.
- B. Clear the catheter with water after suctioning for reuse.
- C. Apply suction for no more than 15 seconds.
- D. Establish a regular schedule for suctioning.
Correct Answer: C
Rationale: Limiting suction to 15 seconds prevents hypoxia and tissue damage during tracheostomy suctioning.
What intervention should the nurse implement after topical administration of hydrocortisone cream to the buttocks and abdomen of an infant?
- A. Diaper the infant snugly with a disposable diaper.
- B. Cover the area with a transparent dressing.
- C. Apply a cloth diaper.
- D. Place the infant on a plastic pad, undiapered.
Correct Answer: C
Rationale: Using a cloth diaper or leaving the infant undiapered on a cloth pad prevents increased drug absorption from plastic coverings.
Which intervention is correct when a nurse is administering a gastrostomy feeding by gravity?
- A. Discard the residual and increase the volume of feeding by the amount of residual.
- B. Flush the gastrostomy tube with 2 to 4 ounces of water before the feeding.
- C. Refill the syringe with formula after it has completely emptied.
- D. Position the child on the right side after a feeding.
Correct Answer: D
Rationale: Positioning on the right side after feeding promotes gastric emptying and prevents regurgitation.