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Which would be best for the nurse to use when determining the temperature of a preterm infant under a radiant heater?
- A. Axillary sensor TestBankWorld.org
- B. Tympanic membrane sensor
- C. Rectal mercury glass thermometer
- D. Rectal electronic thermometer
Correct Answer: B
Rationale: A tympanic membrane sensor or tympanic thermometer is the best option for determining the temperature of a preterm infant under a radiant heater. Tympanic thermometers are quick and non-invasive, making them ideal for use in neonatal care. They provide accurate readings by measuring the infrared heat waves coming from the eardrum. This method is preferred over other options like axillary sensors, rectal mercury thermometers, and rectal electronic thermometers, which may not be as efficient or suitable for use with preterm infants.
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The nurse is caring for a child after heart surgery. What should the nurse do if evidence of cardiac tamponade is found?
- A. Increase analgesia
- B. Apply warming blankets
- C. Immediately report this to physician
- D. Encourage child to cough, turn, and breathe deeply
Correct Answer: C
Rationale: If evidence of cardiac tamponade is found in a child after heart surgery, it is crucial for the nurse to immediately report this to the physician. Cardiac tamponade is a serious condition where excess fluid or blood accumulates in the pericardial sac, compressing the heart and affecting its ability to pump effectively. Prompt recognition and intervention are essential to prevent potential life-threatening outcomes. The physician would need to assess the child's condition, consider performing procedures to relieve the tamponade such as pericardiocentesis, and provide appropriate treatment to stabilize the child. Delaying reporting and action in cases of cardiac tamponade can lead to further complications and worsen the child's condition.
Radiotherapy is an effective modality of treatment in variable pediatric solid tumors. Of the following, the LEAST responsive tumor to radiotherapy is
- A. rhabdomyosarcoma
- B. neuroblastoma
- C. nephroblastoma
- D. osteosarcoma
Correct Answer: D
Rationale: Osteosarcoma is relatively radioresistant compared to other listed tumors.
a hospitalized child with nephrosis is receiving high doses of prednisone. which of the following is an appropriate nursing goal related to this?
- A. prevent infection.
- B. stimulate appetite.
- C. detect evidence of edema.
- D. assist in raising osmotic pressure.
Correct Answer: A
Rationale: High doses of prednisone suppress the immune system, putting the hospitalized child at an increased risk for infections. Therefore, an appropriate nursing goal related to this situation would be to prevent infection by implementing measures such as hand hygiene, maintaining a clean environment, and monitoring for signs and symptoms of infection. It is crucial to protect the child from acquiring additional illnesses while undergoing treatment for nephrosis.
Which blood gas analyses are most indicative of respiratory acidosis?
- A. pH = 7.22, PCO2 = 55 mmHg, HCO3 = 30 mEq/L.
- B. pH = 7.28, PCO2 = 45 mmHg, HCO3 = 15 mEq/L.
- C. pH = 7.34, PCO2 = 35 mmHg, HCO3 = 25 mEq/L.
- D. pH = 7.40, PCO2 = 25 mmHg, HCO3 = 30 mEq/L.
Correct Answer: A
Rationale: Respiratory acidosis is indicated by a low pH and elevated PCO2, as seen in option A.
Nursing interventions for the child after a cardiac catheterization should include which actions? (Select all that apply.)
- A. Allow ambulation as tolerated.
- B. Monitor vital signs every 2 hours.
- C. Assess the affected extremity for temperature and color.
- D. Check pulses above the catheterization site for equality and symmetry.
Correct Answer: A
Rationale: Allowing ambulation as tolerated helps promote circulation and prevent complications such as blood clots.