NCLEX Pediatric
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Question 1 of 5.
The nurse is caring for a preterm infant who must be fed via bolus gavage feeding. The infant has a 5 French feeding tube already secured in the left naris. The nurse has aspirated the infant's stomach contents, noting color, amount, and consistency, and has reinserted the residual amount because it was less than one-fourth the previous feeding. Prioritize the remaining steps that the nurse should take to complete this feeding.
- A. Elevate the syringe 6 to 8 inches over the infant's head.
- B. Position the infant on the right side.
- C. Uncrimp the tubing and allow the feeding to flow by gravity at a slow rate.
- D. Crimp the feeding tube and pour the specified amount of formula or breast milk into the barrel.
- E. Cap the lavage feeding tube.
- D. Crimp the feeding tube and pour the specified amount of formula or breast milk into the barrel.
- A. Elevate the syringe 6 to 8 inches over the infant's head.
- C. Uncrimp the tubing and allow the feeding to flow by gravity at a slow rate.
- E. Cap the lavage feeding tube.
- B. Position the infant on the right side.
Correct arrangement
Explanation: Sequence: Position infant on right side (D) to reduce aspiration risk connect syringe barrel (A) crimp tube and pour formula (F) elevate syringe (C) uncrimp for gravity flow (E) clear tubing with air (B) cap tube (G).
Question 2 of 5.
The nurse would expect to withhold penicillin V (Pen-Vee-K) and notify the physician if the child had a previous allergic reaction to a medication from which drug group?
A. Aminoglycosides
B. Cephalosporins
C. Macrolides
D. Sulfonamides
Explanation: Penicillin V is a penicillin antibiotic, and cephalosporins have a similar beta-lactam structure, which can lead to cross-reactivity in patients with penicillin allergies. Withholding penicillin and notifying the physician is necessary if the child has a cephalosporin allergy.
Question 3 of 5.
Which findings by the nurse best indicate that the child is experiencing diabetic ketoacidosis? Select all that apply.
A. Blood glucose level of 120 mg/dL
B. Fruity-smelling breath
C. Pale-colored face
D. Excessive perspiration
E. Deep, rapid breathing
F. Dry, flushed skin
Explanation: Diabetic ketoacidosis (DKA) is characterized by hyperglycemia (blood glucose typically >250 mg/dL, so 120 mg/dL is incorrect), fruity-smelling breath due to acetone, deep and rapid breathing (Kussmaul respirations) to compensate for acidosis, and dry, flushed skin due to dehydration.
Question 4 of 5.
Which of the following is the priority nursing action if the child shows symptoms of hypoglycemic reaction?
A. Give the child orange juice or milk to drink.
B. Give the child 10% glucose I.V.
C. Notify the physician immediately.
D. Administer a second dose of insulin.
Explanation: For hypoglycemia, the priority is to rapidly raise blood glucose. Giving orange juice or milk provides quick-acting carbohydrates, the first-line treatment for conscious patients with mild to moderate hypoglycemia.
Question 5 of 5.
Which nursing interventions are essential to restore the child's fluid and electrolyte balance during the emergent phase of burn care and treatment? Select all that apply.
A. Initiate the administration of I.V. fluids.
B. Track the child's vital signs.
C. Give the child sips of water.
D. Encourage the child to consume protein-rich feedings.
E. Monitor the child's urine output.
F. Assemble equipment for a small-gauge venous catheter.
Explanation: During the emergent phase, I.V. fluids restore fluid and electrolyte balance due to massive losses. Monitoring vital signs and urine output assesses fluid status, and preparing venous access ensures timely administration. Oral fluids and protein-rich feedings are inappropriate due to gastrointestinal dysfunction.