The nurse is caring for a 9-year-old child admitted with asthma. During the morning rounds, the nurse finds an O2 sat of 78%. Which of the following actions should the nurse take first?
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Solution
Answer C is correct. The child with an oxygen saturation level of 78% is hypoxic. He will require oxygen therapy. Checking the arterial blood gases in answer A is good but is not the highest priority and will not correct the problem. If the nurse does nothing, as in answer B, the client’s condition will most likely continue to decline. Answer D is incorrect because assessing the pulse will probably reveal tachycardia, but this is not the highest priority.
The nurse is providing dietary instructions to the mother of an 8-year-old child diagnosed with celiac disease. Which of the following foods, if selected by the mother, would indicate her understanding of the dietary instructions?
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Solution
Answer D is correct. The child with celiac disease should be on a gluten-free diet. Answer D is the only choice of foods that do not contain gluten, so answers A, B, and C are incorrect
The 45-year-old client is seen in the clinic with hyperthyroidism. What would the nurse expect the admitting assessment to reveal?
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Solution
Answer C is correct. Exophthalmos (protrusion of eyeballs) often occurs with hyperthyroidism. The client with hyperthyroidism will often exhibit tachycardia, increased appetite, and weight loss, not bradycardia, decreased appetite, or weight gain, so answers A, B, and D are incorrect.
The nurse is caring for a client admitted with acute laryngotracheobronchitis (LTB). Because of the possibility of complete obstruction of the airway, which of the following should the nurse have available?
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Solution
Answer B is correct. For a child with LTB and the possibility of complete obstruction of the airway, emergency intubation equipment should always be kept at the bedside. Intravenous supplies and fluid will not treat an obstruction, so answers A and C are incorrect. Answer D is incorrect because although supplemental oxygen is needed, the child will need to be intubated for it to help.
A client with bacterial pneumonia is admitted to the pediatric unit. What would the nurse expect the admitting assessment to reveal?
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Solution
Answer A is correct. If the child has bacterial pneumonia, a high fever is usually present. Bacterial pneumonia usually presents with a productive cough, not a nonproductive cough, so answer B is incorrect. Rhinitis is often seen with viral pneumonia, not bacterial pneumonia, so answer C is incorrect. Vomiting and diarrhea are usually not seen with pneumonia, so answer D is incorrect.
A priority nursing diagnosis for a child being admitted from surgery following a tonsillectomy is:
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Solution
Answer C is correct. A risk for aspiration is the best answer because aspiration of blood can lead to airway obstruction. Answer A does not apply to a child who has undergone a tonsillectomy because there is no alteration in body image. Answer B is incorrect because impaired verbal communication might be true but is not the highest priority. Pain is an issue, but not the highest priority, so answer D is incorrect.
Which instruction should be given to the client who is fitted for a behind-the-ear hearing aid?
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Solution
Answer B is correct. Hearing aids should be stored in a cool place in order to preserve the life of the battery. Answer A is incorrect because the mold should be cleaned daily. Answer C is incorrect because the hearing aid should not be cleaned with a toothpick. Answer D is incorrect because changing the batteries weekly is not necessary.
A 2-year-old toddler is seen in the pediatrician’s office. During physical assessment, the nurse would anticipate the need for which intervention?
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Solution
Answer C is correct. There is no reason to tell the parents to leave because this might cause the child to become more agitated, making answer A incorrect. Removing his toys may also cause him to fret and make the examination more difficult, so answer B is incorrect. Answer D is incorrect because telling him that the behavior is inappropriate will not help because the child is too young to understand.
The nurse is discussing meal planning with the mother of a 2- year-old toddler. Which of the following statements, if made by the mother, would require a need for further instruction?
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Solution
Answer C is correct. The comment of most concern is answer C because hot dogs are commonly the cause of choking in children. There is no reason for concern in the comments in answers A, B, or D; therefore, these are incorrect.
The nurse is caring for a 6-year-old client admitted with the diagnosis of conjunctivitis. Before administering eyedrops, the nurse should recognize that it is essential to consider which of the following?
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Solution
Answer A is correct. Before instilling eyedrops, the nurse should cleanse the area with water. A 6-year-old child is not developmentally ready to instill his own eyedrops, so answer B is incorrect. Although the mother of the child may instill the eyedrops, the area must be cleansed before administration, so answer C is incorrect. The eye might appear to be clear, but the nurse should instill the eyedrops, as ordered, so answer D is incorrect.