A 12 month old is admitted w/ a respiratory infection and possible pneumonia. He is placed in a
mist tent w/ O2. Which nsg intervention has the greatest priority? - ANS - Have a bulb syringe
readily available to remove secretions
(patent airway has the highest priority. Humidification will liquefy the nasal secretions - thereby
increasing the amt of secretions and making that a priority)
A 14 yr old female tells the nurse that she is concerned about the acne she has recently dvp'd.
Which recommendation should the nurse provide? - ANS - Wash the hair and skin frequently w/
soap and hot water
(washing the hair and skin w/ soap and water removes oil and debris from the skin and helps
prevent and tx acne. Oily skin is especially bothersome during adolescence when hormones
cause enlargement of sebaceous glands and increased glandular secretions which predispose
the teenager to acne.)
A 15 yr old girl tells the school nurse that all of her friends have started their periods and she
feels abnormal because she has not. Which response is best for the nurse provide? - ANS -
Explain that menarche varies and occurs at 12-18 yrs old
A 16 yr old is brought to the ER w/ a crushed leg after falling off a horse. The adolescent's last
tetanus toxoid booster was received eight yrs ago. What action should the nurse take? - ANS -
Administer tetanus toxoid booster
(After the completion of the initial completion of the initial tetanus immunization schedule, the
recommended booster for an adolescent or adult is every 10 yrs or less if a traumatic injury
occurs that is contaminated by dirt, feces, soil, or saliva, such as puncture or crushing injuries,
avulsions, wounds from missiles, burns, or frostbite. the adolescent's injury is considered a
contaminated wound requiring prophylactic therapy, so the tetanus toxoid booster should be
administered)
A 17 yr old male student reports to the school clinic one morning for a scheduled health exam.
He tells the nurse that he just finished football practice and is on his way to class. the nurse
assesses his v/s: Temp 100F, Pulse 80, RR 20, and BP 122/82. what is the best action for the
nurse to take? - ANS - Tell the student to proceed directly to his regularly scheduled class
A 2 yr old child recently diagnosed w/ hemophilia A is discharged home. What info should the
nurse include in a teaching plan about home care? - ANS - Apply pressure and ice for bleeding
while elevating and resting the extremity
, (Hemophilia, a blood disorder, causes joint bleeding which is treated w/ rest, ice, compression,
and elevation (RICE) )
A 2 yr old child w/ gastro-esophageal reflux has dvpd a fear of eating. What instruction should
the nurse include in the parents' teaching plan? - ANS - Consistently follow a set mealtime
routine
(2 yr olds are comforted by consistency)
A 2 yr old w/ Down syndrome is brought to the clinic for his regular physical exam. The nurse
knows which problem is requently associated w/ Downs? - ANS - Congenital heart disease
(CHD is the most common associated defect w/ Downs. - also, remember Professor Moore said
that heart and ear problems go hand in hand)
A 3 month old infant dvps oral thrush. Which pharmacologic agent should the nurse plan to
administer for tx of this disorder? - ANS - Nystatin (Mycostatin)
(this is an antifungal drug that is effective in tx'g thrush, an oral fungal infection)
A 3 month old weighing 10 #, 15 oz has an axillary temp of 98.9F. The nurse determines the
daily caloric need for him as approximately - ANS - 600 calories/ day
(10# 15 oz = 10.9#. Convert # to kg and rounded to 5.
10.9/2.2=4.954 = 5kg. An infant requires 108 calories/kg/day. So, 108 * 5 = 540 cal/day.
however, this infant requires 10% more because he has a one degree tempt elevation. so 10%
of 540 is 54. So 540 + 54 = 594)
A 3 wk old newborn is brought to the clinic for f/u after a home birth. the mother reports that her
child bottle feeds for 5 min only and then falls asleep. the nurse auscultates a loud murmur
characteristic of a VSD, and finds the newborn is acyanotic w/ a RR 64. What instruction should
then nurse provide the mother to ensure the infant is receiving adequate intake? - ANS - 1.
Monitor the infant's wt and # of wet diapers per day
2. Increase the infant's intake per feeding by 1-2 oz per week
3. Allow the infant to rest and refeed on demand or every 2 hrs
4. Use a softer nipple or increase the size of the nipple opening
(Neonates who have VSD may fatigue quickly during feeding and ingest inadequate amts. They
should be monitored for wt gain at least 6 wet diapers/day. A 1 month old infant should ingest
2-4 oz of formula per feeding and progress to about 30 uz / day by 4 months of age. Due to
fatigue, the infant should rest, but feed at least q2h to ensure adequate intake. A softer preemie
nipple or a larger slit in the nipple helps to reduce the sucking effort and energy expenditure,
thus allowing the infant to ingest more w/ less effort )
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