a nurse is planning care for a child who has severe diarrhea. which of the following actions is the nurse priority?
A. Introduce a regular diet
B. Rehydr... [Show More] ate
C. Maintain fluid therapy
D. Assess fluid balance
(Assess first the other three are interventions, before u intervene you have to assess how much fluid imbalance. Check for labs results because it will tell you what kind of fluid is to be given and how much fluid to be replaced. Priority is assessment first)
A nurse is caring for a toddler who’s parent states that the child has a mass in his abdominal area and his urine is a pink color. Which of the following actions is the nurse’s priority?
A. Schedule the child for an abdominal ultrasound
B. Instruct the parent to avoid pressing on the abdominal area
C. Determine if the child is having pain
D. Obtain a urine specimen for a urinalysis
A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions is the nurse’s priority?
A. Place the child on a no salt added diet
B. Check the Childs weight daily
C. Educate the parents about potential complications
D. Maintain a saline lock (IV access that is attached to any fluids. For emergency)
(inflammation of the kidneys caused by group A beta hemolytic streptococcus, infection. Fluid or fluid retention. Patient with kidney problems affect blood pressure -> High blood pressure because of fluid retention. Salt increases high blood pressure. Lower the salt intake of this patient)
A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following is the nurse’s priority?
A. Administer antibiotics when available
B. Reduce environmental stimuli (because of increase of ICP and can cause seizures)
C. Document intake and output
D. Maintain seizure precautions
A nurse is collecting data from an adolescent. Which of the following represents the greatest risk for suicide?
A. Availability of firearms
B. Family conflict
C. Homosexuality
D. Active psychiatric disorder (Mark, mental problems, patients mind is unstable)
A nurse is collecting data from an infant who has otitis media (middle ear infection). The nurse should expect which of the following findings?
A. Tugging on the affected ear lobe
B. Bluish green discharge from the ear canal (there’s usually no discharge, discharge only comes out if there’s opening in the ear drum)
C. Increase in appetite (decrease in appetite)
D. Erythema and edema of the affected auricle (usually no redness in the affected auricle)
(otitis externa: infection of the outer ear)
A nurse is reinforcing reaching with a parent of a 1 month old infant who is to undergo the initial surgery to treat Hirschsprung’s disease (a ganglionic megacolon, part of the colon isn’t connected to the nerves or not functioning, so there will be an increase size of the colon and stool gets stuck in there). Which of the following statements should indicate to the nurse that the parent understanding the goal of surgery?
A. “I’m glad that the ostomy is only temporary “ (1st there going to cut the nonfunctioning of the colon, and then apply temporary colostomy, after a couple of months they will suture it together)
B. “I’m glad my child will have normal bowel movements now”
C. “I want to learn how to use the feeding tube as soon as possible”
D. “the operation will straighten out the kink in the intestine”
A nurse is caring for an infant who is 1 day postoperative following surgical repair of a cleft lip. Which of the following actions should the nurse take?
A. Apply an antibiotic ointment to the suture site
B. Clear oral secretions using a bulb syringe
C. Feed the infant using a spoon
D. Position the infant on her abdomen
A nurse is reinforcing discharge instructions with a parent of a child who has cystic fibrosis. Which of the following statements by the parent indicates an understanding of the teaching?
A. “I will make sure my child washes her hands before eating”
B. “I will restrict the amount of salt in my child’s meal”
C. “I will put my child in daycare to ensure that she socializes with other
children”
D. “I will provide low fat meals for my child
A nurse working at a clinic speaks on the telephone with a parent of a 2-month- old infant. The parent tells the nurse that the infant has projectile vomiting followed by hunger after meals. Which of the following response by the nurse is appropriate?
A. “Bring your infant into the clinic today to be seen”
B. “Burp your child more frequently during feedings”
C. “Give your infant an oral rehydrating solution”
D. “You might want to try switching to different formula”
A nurse is caring for a 4 year old child who is 2 days postoperative following the insertion of a ventriculoperitoneal shunt. Which of the following findings should the nurse identify as the priority . (causes icp hydrocephalus)
A. lethargy (high pitched cry, respiratory changes, bradycardia, wide pulse pressure, irritability)
B. lying flat on the unaffected side
C. respiratory rate 20/min
D. urine output 50 mL in 2hr
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