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A nurse is caring for a child who is on a clear liquid diet. At lunch, the child consumed ½ cup of juice, 3 oz gelatin. 1 oz of an ice pop, and 20 mL ginger ale. How many mL should the nurse record as the child's fluid intake?

Answer and Explanation

The Correct Answer is ["260"]

Step 1: Convert ½ cup of juice to mL. 1 cup = 240 mL ½ cup = 240 mL ÷ 2 = 120 mL Result: 120 mL

Step 2: Convert 3 oz of gelatin to mL. 1 oz = 30 mL 3 oz = 3 × 30 mL = 90 mL Result: 90 mL

Step 3: Convert 1 oz of an ice pop to mL. 1 oz = 30 mL 1 oz = 1 × 30 mL = 30 mL Result: 30 mL

Step 4: Ginger ale is already in mL. Result: 20 mL

Step 5: Add all the mL values together. 120 mL + 90 mL + 30 mL + 20 mL = 260 mL Result: 260 mL

The nurse should record the child’s fluid intake as 260 mL.

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Correct Answer is D

Explanation

When a school nurse suspects that a child is being sexually abused, the priority action is to ensure the child's safety and well-being. Option D, accurately and thoroughly documenting the findings and reporting to the appropriate authorities, is the most critical step in protecting the child.

Child abuse, including sexual abuse, is a serious concern that requires immediate attention and intervention. In many jurisdictions, healthcare professionals, including school nurses, are mandated reporters, which means they are legally obligated to report suspected cases of child abuse to child protective services or other appropriate authorities.

Options A, B, and C are not appropriate as the child's safety is the top priority:

A. Discussing the findings with the parents and giving them the opportunity to explain could potentially place the child at further risk if the parents are involved in the abuse or are unwilling to address the situation.

B. Talking to the child and finding out if they are experiencing sexual abuse or inappropriate touching should not be the first step without involving child protective services or other appropriate authorities. The child may be frightened or reluctant to disclose abuse directly to the nurse, especially if the abuser is a family member or someone known to the child.

C. Talking with another co-worker to confirm the assessment may delay the necessary action and reporting to protect the child.

A. Place the client on bed rest in a semi-Fowler's position. B. Instruct the client to limit fluid intake to less than 2.000 mL/day. C. Prepare to administer antibiotics. D. Repeat auscultation after asking the client to breathe deeply and cough

Correct Answer is D

Explanation

A-Positioning in semi-Fowler’s can aid breathing but doesn’t assess crackles’ cause. It’s supportive, not diagnostic, and premature without further data

B-Instructing the client to limit fluid intake to less than 2,000 mL/day is not indicated for crackles. Fluid restriction is more commonly used in conditions like congestive heart failure where there is excessive fluid retention.

C- Preparing to administer antibiotics is not the first intervention for crackles. Crackles can be caused by various conditions, and antibiotics would only be administered if there is an underlying infection requiring treatment.

D- Reassessing after deep breathing and coughing evaluates secretion clearance, aligning with nursing assessment and Maslow’s physiological needs

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A nurse is caring for a child who is on a clear liquid diet. At lunch, the child consumed ½ cup of juice, 3 oz gelatin. 1 oz of an ice pop, and 20 mL ginger ale. How many mL should the nurse record as the child's fluid intake?

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Naxlex Comprehensive Predictor Exams

The school nurse is seeing a 7-year-old child in the clinic and is concerned with behaviors and physical indications that indicate the child is being sexually abused. Which is the priority action by the nurse?

Correct Answer is D

Explanation

A nurse auscultates a client's lung sounds and identifies crackles in the left lower lobe. Which of the following interventions should the nurse take

Correct Answer is D

Explanation

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