Which of the following interventions should the nurse include in the plan of care

Which of the following interventions should the nurse include in the plan of care
1) A nurse is assisting a child who has multiple closed fractures of the lower extremities due to a motor-vehicle crash. The nurse should monitor the child for which of the following complications during the first 24 hr after the injury occurred?
a. Osteomyelitis
b. Compartment syndrome
c. Volkmann ischemic contracture
d. Renal calculi
2) A nurse is teaching the parent of a toddler who has phenylketonuria about meal planning. Which of the following information should the nurse include in the teaching?
a. Use aspartame as sugar substitute
b. Avoid foods containing milk products
c. Increase the toddlers protein consumption
d. Limit foods high in iron
3) A nurse at an inpatient facility is planning care for a child who has autism spectrum disorder. Which of the following interventions should the nurse include in the plan of care?
a. Vary daily routines when providing care for the child
b. Keep the television on in the child’s room for background noise
c. Keep staff visits with the child brief
d. Place the child in a semi private room.
4) A nurse is assisting an infant who has severe dehydration due to gastroenteritis. Which of the following findings should the nurse expect?
a. Increase urine output
b. Hypertension
c. Increase respiratory rate
d. Capillary refill of 2 seconds
5) A nurse is planning care for a child who has cystic fibrosis. Which of the following interventions should the nurse plan to include?
a. Restrict the child’s physical activity to promote rest
b. Administer pancreatic enzymes by mouth 1 hr. prior to each meal
c. Provide the child with low sodium diet
d. Use a vest to perform high-frequency chest compressions
6) A nurse is teaching the parent of a school age child about bicycle safety. Which of the following instructions should the nurse include in the teaching?
a. Your child’s feet should be 3 to 6 inches off the ground when seated on the bicycle
b. Your child should walk the bicycle through intersections
c. Your child should keep the bicycle at least 3 feet from the curb while riding in the street
d. Your child should ride the bicycle against the flow of traffic
7) A nurse is preparing a child for a lumbar puncture. In which of the following positions should the child be placed for the procedure?
a. Lateral
b. Prone
c. Semi-fowler
d. Supine
8) A nurse is reviewing the complete blood count results for a child who is receiving treatment for acute lymphoblastic leukemia. Which of the following findings should indicate to the nurse that the treatment is having a therapeutic effect?
a. WBC count 15.000/mm
b. Hemoglobin 6.8 g/dL
c. Platelet count 98.0000/mm
d. RBC count 5/mm
9) A nurse is caring for a school age child who has pertussis. Which of the following actions should the nurse take?
a. Report the diagnosis to the public health department
b. Place the child in a protected environment for 48hr
c. Administer the pertussis vaccine
d. Restrict oral fluids to 500mL per day
10) A nurse is assessing a week old infant. The nurse should identify which of the following manifestations can indicate neonatal abstinence syndrome?
a. Frequent coughing
b. Constipation
c. Excessive sucking
d. Lethargy
11 )A nurse is preparing to initiate IV antibiotic therapy for a newly admitted 12 month-old infant. Which of the following actions should the nurse plan to take?
a. Use a 12 gauge catheter to the start the IV
b. Start the IV in the infant’s foot
c. Cover the insertion site with an opaque dressing
d. Change the IV site every 3 days
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