Which statement by the child indicates a need for further te...

Which statement by the child indicates a need for further teaching about bicycle safety?

A. I'll wear my helmet whenever I ride my bicycle.
B. I'll ride my bicycle in the opposite direction of traffic flow.
C. I'll stop at all intersections and look both ways before proceeding.
D. I won't ride my bicycle after dark on the street.

Correct Answer: B

Rationale: Riding in the opposite direction of traffic flow is unsafe, increasing collision risk. Bicycles should be ridden with traffic flow, indicating a need for further teaching.

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Which nursing action is most appropriate at this time?

A. Recognize that the fluid is cerebrospinal fluid (CSF) and remove the dressing, observing for the source of the leakage.
B. Recognize that the fluid is CSF and call the chaplain because death of the child is imminent.
C. Recognize that the fluid is CSF and notify the operating room because additional surgery will be necessary.
D. Recognize that the fluid is CSF and reinforce the dressing until the physician can change it.

Correct Answer: D

Rationale: Clear drainage on a head dressing post-craniotomy is likely CSF, indicating a leak. Reinforcing the dressing prevents infection and maintains a sterile barrier until the physician assesses the leak.

The nurse is caring for the newborn infant. Which initial measures should the nurse take to maintain the newborn’s axillary body temperature between 97.7°F (36.5°C) and 98.9°F (37.2°C)? Select all that apply.

A. Carefully dry the infant immediately after birth.
B. Place the infant skin-to-skin with the mother.
C. Apply leggings to both of the newborn’s legs.
D. Cover the infant’s head with a stocking cap.
E. Place the infant in a bassinette close to the wall.

Correct Answer: A,B,D

Rationale: Drying the newborn prevents heat loss through evaporation. Skin-to-skin contact with the mother assists in maintaining body temperature. A stocking cap conserves heat. Leggings are unnecessary and placing the bassinette near a wall causes radiation heat loss.

The nurse informs the client that acquired immunodeficiency syndrome (AIDS) is commonly associated with which symptoms?

A. Increased appetite and chills during the night
B. Tachycardia, dyspnea, and constipation
C. Fatigue, fever, and persistent yeast infections
D. Weight gain, peripheral edema, and jaundice

Correct Answer: C

Rationale: AIDS is associated with fatigue, fever, and persistent infections like yeast infections due to immune suppression, making these symptoms characteristic.

Which nursing instruction is correct for the parents of a child who has a vitamin D deficiency?

A. Give the child cod liver oil daily.
B. Give the child orange juice daily.
C. Apply sunblock to the child before sun exposure.
D. Keep the child indoors during daylight hours.

Correct Answer: A

Rationale: Cod liver oil is a rich source of vitamin D, essential for correcting vitamin D deficiency and supporting bone health.

If the child weighs 30 kg, what is the hourly flow rate in milliliters? Use the standard 100 mL/kg/day for the first 10 kg of body weight, 50 mL/kg/day for the next 10 kg of body weight, and 20 mL/kg/day for each kilogram above 20 kg of body weight for daily maintenance.

Correct Answer: 70.83 mL/hour

Rationale: Calculation: First 10 kg = 100 mL/kg/day × 10 = 1000 mL/day; Next 10 kg = 50 mL/kg/day × 10 = 500 mL/day; Last 10 kg = 20 mL/kg/day × 10 = 200 mL/day. Total = 1000 + 500 + 200 = 1700 mL/day. Hourly rate = 1700 ÷ 24 = 70.83 mL/hour. Since no exact option is provided, the closest reasonable answer is assumed as correct based on standard practice.