The nurse calculates the amount of an antibiotic for injection to be given to an infant. The amount of medication to be administered is 1.25mL. The nurse should:
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Solution
Answer A is correct. No more than 1mL should be given in the vastus lateralis of the infant. Answers B, C, and D are incorrect because the dorsogluteal and ventrogluteal muscles are not used for injections in the infant.
The nurse is teaching the mother of a child with cystic fibrosis how to do postural drainage. The nurse should tell the mother to:
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Solution
Answer D is correct. The nurse or parent should use a cupped hand when performing chest percussion. Answer A is incorrect because the hand should be cupped. Answer B is incorrect because the child’s position should be changed every 5–10 minutes and the whole session should be limited to 20 minutes. Answer D is incorrect because chest percussion should be done before meals.
Which of the following pediatric clients is at greatest risk for latex allergy?
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Solution
Answer A is correct. The child with myelomeningocele is at greatest risk for the development of latex allergy because of repeated exposure to latex products during surgery and from numerous urinary catheterizations. Answers B, C, and D are much less likely to be exposed to latex; therefore, they are incorrect.
At the 6-week check-up, the mother asks when she can expect the baby to sleep all night. The nurse should tell the mother that most infants begin to sleep all night by age:
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Solution
Answer C is correct. Most infants begin nocturnal sleep lasting 9–11 hours by 3–4 months of age. Answers A and B are incorrect because the infant is still waking for nighttime feedings. Answer D is incorrect because it does not answer the question.
The nurse is caring for a 4-year-old with cerebral palsy. Which nursing intervention will help ready the child for rehabilitative services?
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Solution
Answer B is correct. The nurse can help ready the child with cerebral palsy for speech therapy by providing activities that help the child develop tongue control. Most children with cerebral palsy have visual and auditory difficulties that require glasses or hearing devices rather than rehabilitative training; therefore, answers A and C are incorrect. Answer D is incorrect because video games are not appropriate for the age or developmental level of the child with cerebral palsy.
A client with AIDS complains of a weight loss of 20 pounds in the past month. Which diet is suggested for the client with AIDS?
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Solution
Answer D is correct. The suggested diet for the client with AIDS is one that is high calorie, high protein, and low fat. Clients with AIDS have a reduced tolerance to fat because of the disease as well as side effects from some antiviral medications; therefore, answers A and C are incorrect. Answer B is incorrect because the client needs a high-protein diet.
The diagnostic work-up of a client hospitalized with complaints of progressive weakness and fatigue confirms a diagnosis of myasthenia gravis. The medication used to treat myasthenia gravis is:
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Solution
Answer A is correct. Protigmine is used to treat clients with myasthenia gravis. Answer B is incorrect because it is used to reverse the effects of neostigmine. Answer C is incorrect because the drug is unrelated to the treatment of myasthenia gravis. Answer D is incorrect because it is the test for myasthenia gravis.
A client with diverticulitis is admitted with nausea, vomiting, and dehydration. Which finding suggests a complication of diverticulitis?
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Solution
Answer B is correct. A rigid or boardlike abdomen is suggestive of peritonitis, which is a complication of diverticulitis. Answers A, C, and D are common findings in diverticulitis; therefore, they are incorrect.
Physician’s orders for a client with acute pancreatitis include the following: strict NPO, NG tube to low intermittent suction. The nurse recognizes that these interventions will:
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Solution
Answer A is correct. Placing the client on strict NPO status will stop the inflammatory process by reducing the secretion of pancreatic enzymes. The use of low, intermittent suction prevents release of secretion in the duodenum. Answer B is incorrect because the client requires exogenous insulin. Answer C is incorrect because it does not prevent the secretion of gastric acid. Answer D is incorrect because it does not eliminate the need for analgesia.
The nurse is teaching the parents of a newborn with osteogenesis imperfecta. The nurse should tell the parents:
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Solution
Answer B is correct. To prevent fractures, the parents should lift the baby by the buttocks rather than the ankles when diapering. Answer A is incorrect because children with osteogenesis imperfecta have normal calcium and phosphorus levels. Answer C is incorrect because the condition is not temporary. Answer D is incorrect because the teeth and the sclera are also affected.