Question

A nurse is caring for client who has sepsis and a prescription for vancomycin 1 g in 250 mL dextrose 5% (D₅W) over 2 hr by IV intermittent bolus. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

Answer 1

Correct Answers:

125

Rationale :

🔷 Calculation: Total volume (250 mL) ÷ Total time (2 hr) = 125 mL/hr

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Answer 2

Correct Answers:

“Keep a night light on in your child’s room."

Rationale :

🔷 Night lights provide reassurance and help reduce fear of monsters, which is common in preschoolers with active imaginations.

🔷 Promotes emotional security, helping the child transition to sleep independently.

🔷 Addresses developmental stage needs (Erikson: initiative vs guilt), where fears are common.

🔷 Maintains healthy sleep habits by allowing the child to remain in their own bed rather than co-sleeping.

🔷 Reinforces coping mechanisms by providing comfort rather than dismissing the child’s fears.

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Answer 3

Correct Answers:

Iron deficiency anemia

Rationale :

🔷 Excessive milk intake decreases consumption of iron-rich solid foods, causing nutritional deficiency.

🔷 Milk interferes with iron absorption, worsening anemia risk.

🔷 Iron deficiency leads to pallor, fatigue, and developmental delays if untreated.

🔷 Toddlers need balanced nutrition to prevent long-term growth problems.

🔷 Education on dietary variety is essential for preventing microcytic anemia.

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Answer 4

Correct Answers:

Prepare for nasotracheal intubation.

Rationale :

🔷 Severe dyspnea and drooling indicate epiglottitis, a life-threatening airway obstruction.

🔷 Airway maintenance is priority (ABC rule in pediatrics).

🔷 Manipulating the throat can worsen obstruction, so preparation for intubation is essential.

🔷 Immediate airway management prevents hypoxia and respiratory arrest.

🔷 Emergency equipment readiness is critical in epiglottitis care.

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Answer 5

Correct Answers:

Clear breath sounds

Rationale :

🔷 Indicates effective suctioning, as secretions that caused obstruction are cleared.

🔷 Stable oxygenation confirms improved ventilation and gas exchange.

🔷 Prevents atelectasis by ensuring airway patency.

🔷 Monitored breath sounds help evaluate need for further suctioning.

🔷 Proper suctioning technique prevents mucosal trauma while restoring airway clearance.

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Answer 6

Correct Answers:

"The rate and rhythm of breath are irregular in newborns."

Rationale :

🔷 Newborns have periodic breathing, so a full minute ensures accurate assessment.

🔷 Short counting may miss apnea episodes, which are critical in newborn assessment.

🔷 Irregular respiratory rhythm is normal but requires consistent evaluation.

🔷 Prevents misinterpretation of respiratory distress by ensuring accurate rate documentation.

🔷 Full-minute counting follows pediatric assessment standards.

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Answer 7

Correct Answers:

Apply sunction for less than 10 seconds.

Rationale :

🔷 Prolonged suctioning can cause hypoxia, so limiting time preserves oxygenation.

🔷 Reduces mucosal trauma, preventing airway edema or bleeding.

🔷 Short suctioning intervals allow adequate rest, preventing fatigue.

🔷 Prevents bradycardia, which can occur from vagal stimulation.

🔷 Ensures efficient secretion removal without compromising ventilation.

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Answer 8

Correct Answers:

Frequent swallowing

Rationale :

🔷 Indicates bleeding as the child repeatedly swallows blood trickling down the throat.

🔷 Post-tonsillectomy hemorrhage is life-threatening and requires immediate intervention.

🔷 Other signs may include tachycardia and pallor, so early detection is vital.

🔷 Frequent swallowing often occurs before visible bleeding, making it a key early sign.

🔷 Monitoring and rapid response can prevent hypovolemic shock.

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Answer 9

Correct Answers:

Agitation

Rationale :

🔷 Hypoxemia stimulates the sympathetic nervous system, causing restlessness and agitation.

🔷 Agitation is an early sign, preceding cyanosis or confusion.

🔷 Unrelieved hypoxia can progress to lethargy and respiratory failure if untreated.

🔷 Continuous observation ensures early intervention with oxygen therapy.

🔷 Prompt response improves airway management outcomes.

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Answer 10

Correct Answers:

“Avoid triggers that cause an attack."

Rationale :

🔷 Prevention is the cornerstone of asthma management to reduce exacerbations.

🔷 Identifying allergens and irritants helps maintain long-term control.

🔷 Consistent trigger avoidance reduces need for emergency medications.

🔷 Empowers the child and family to self-manage the chronic condition.

🔷 Decreases school absences and improves quality of life.

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QLexNursing

2 :
The parent of a 4-year-old child tells a nurse that the child believes there are monsters hiding in the closet at bedtime. Which one of the following statements should the nurse make?

3 :
A parent tens a nurse that her toddler drinks a quart of milk a day and has a poor appetite for solid foods. The nurse should explain that the toddler is at risk which of the following disorders?

4 :
A nurse in an emergency department is assessing a 3-year-old child who has a high fever, severe dyspnea, and is drooling. Which of the following actions is the nurse’s priority?

5 :
A nurse is caring for a child who has a tracheostomy. After suctioning the tracheostomy, the nurse should use which of the following findings to determine that the procedure was effective?

6 :
A nurse is teaching an assistive personnel to measure a newborn's respiratory rate. Which of the following statements indicates an understanding of why the respiratory rate should be counted for a complete minute?

7 :
A home health nurse is teaching a child's parents about endotracheal suctioning. Which of the following information should the nurse include in the teaching?

8 :
A nurse is monitoring a child for manifestations of hemorrhage following a tonsillectomy. Which of the following findings is a manifestation of this postoperative complication?

9 :
A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect

10 :
A nurse is providing education to a school-age child who has a new diagnosis of asthma. Which of the following statements should the nurse include in the teaching?

QLexNursing

2 : The parent of a 4-year-old child tells a nurse that the child believes there are monsters hiding in the closet at bedtime. Which one of the following statements should the nurse make?

3 : A parent tens a nurse that her toddler drinks a quart of milk a day and has a poor appetite for solid foods. The nurse should explain that the toddler is at risk which of the following disorders?

4 : A nurse in an emergency department is assessing a 3-year-old child who has a high fever, severe dyspnea, and is drooling. Which of the following actions is the nurse’s priority?

5 : A nurse is caring for a child who has a tracheostomy. After suctioning the tracheostomy, the nurse should use which of the following findings to determine that the procedure was effective?

6 : A nurse is teaching an assistive personnel to measure a newborn's respiratory rate. Which of the following statements indicates an understanding of why the respiratory rate should be counted for a complete minute?

7 : A home health nurse is teaching a child's parents about endotracheal suctioning. Which of the following information should the nurse include in the teaching?

8 : A nurse is monitoring a child for manifestations of hemorrhage following a tonsillectomy. Which of the following findings is a manifestation of this postoperative complication?

9 : A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect

10 : A nurse is providing education to a school-age child who has a new diagnosis of asthma. Which of the following statements should the nurse include in the teaching?

2 :
The parent of a 4-year-old child tells a nurse that the child believes there are monsters hiding in the closet at bedtime. Which one of the following statements should the nurse make?

3 :
A parent tens a nurse that her toddler drinks a quart of milk a day and has a poor appetite for solid foods. The nurse should explain that the toddler is at risk which of the following disorders?

4 :
A nurse in an emergency department is assessing a 3-year-old child who has a high fever, severe dyspnea, and is drooling. Which of the following actions is the nurse’s priority?

5 :
A nurse is caring for a child who has a tracheostomy. After suctioning the tracheostomy, the nurse should use which of the following findings to determine that the procedure was effective?

6 :
A nurse is teaching an assistive personnel to measure a newborn's respiratory rate. Which of the following statements indicates an understanding of why the respiratory rate should be counted for a complete minute?

7 :
A home health nurse is teaching a child's parents about endotracheal suctioning. Which of the following information should the nurse include in the teaching?

8 :
A nurse is monitoring a child for manifestations of hemorrhage following a tonsillectomy. Which of the following findings is a manifestation of this postoperative complication?

9 :
A nurse is assessing a client for hypoxemia during an asthma attack. Which of the following manifestations should the nurse expect

10 :
A nurse is providing education to a school-age child who has a new diagnosis of asthma. Which of the following statements should the nurse include in the teaching?