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. Rehydrate
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
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