RN101
Home of the Registered Nurses (RN) and
Licensed Practical Nurses (LPN)

SITUATION I

 

Question 1:

Pyloric stenosis

 

Question 2:

Right side (or in an infant seat)

Justification: These position aid in emptying the stomach and preventing aspiration.

 

SITUATION II

 

Question 1:

Fatty stools (stetorrhea)

 

Question 2:

A high-calorie, high-protein diet

 

Question 3:

Fat soluble vitamins (ADEK)

Rationale: Children with CF are managed with a high-calorie, high-protein diet. Pancreatic enzyme replacement therapy is undertaken, and fat-soluble vitamin supplements are administered. Fats are not restricted unless steatorrhea cannot be controlled by increased levels of pancreatic enzymes.

 

Question 4:

Two hours after meal

 

SITUATION III

 

Question 1:

1. Sunken fontanel

2. Dry mouth or mucous membrane

3. Poor skin turgor

4. Increase heart rate

 

Question 2:

1. Specific gravity is high

2. Hematocrit is high

3. Low urine output

 

Question 3:

1. Proper handwashing

2. Isolation precaution (remove to daycare/school)

3. Proper attachment and disposal of diaper

4. Disinfect of contaminated surfaces

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SITUATION IV

Question 1:

1. Banana

2. Rice

3. Applesauce

4. Toast

5. Tea

6. Yogurt

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For a patient recovering from gastroenteritis nonirritating solid foods are added to the diet first. Foods such as bananas, rice, applesauce, toast (BRAT), tea and yogurt (BRATTY) are provided initially. Milk products are among the last foods reintroduced to the diet because milk and milk products can be hard to digest. However, yogurt helps to recolonize the bowel with beneficial bacteria.

 

SITUATION V

 

Question 1:

Priority problem: Elbow restraint 

Nursing directive: Nurse to remove restraint q 2 hours

 

Question 2:

Rubber dropper

 

SITUATION VI

 

Question 1:

Rectus femoris

 

SITUATION VII

 

Question 1:

4 Pureed fruits

5 Rice cereal

6 Pureed vegetables and ground meat

 

SITUATION VIII

 

Question 1:

1. Colicky, abdominal pain

2. Red currant jelly

3. Vomiting

4. Distended, tender abdomen, sausage shape mass in the right upper quadrant

5. Late sign: fever, shock

 

SITUATION IX

 

Question 1:

Call the doctor immediately

 

SITUATION X

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Question 1:

Administer the medication with a syringe without needle placed alongside of the infant's tongue.

 

The contents are administered slowly in small amounts, allowing the child to swallow between deposits. Medications should be given slowly to avoid aspiration. The medication should be mixed with only a small amount of food or liquid. If the child does not finish drinking/eating, it is difficult to determine how much medication was consumed. Essential foods also should not be used. Holding the child's nasal passages increases the risk of aspiration.

 

SITUATION XI

 

Question 1:

1. Cool mist humidifier at home (hoods and tents)

2. Warm humid compress on the larynx

3. Warm mist by steam from running hot water in closed bathroom/boil water in a casserole or exposure to cold air.

If mild: encourage fluid and cool fruit juice ETC…..

 

SITUATION XII

 

Question 1:

1. 5-6 diaper change in a day

2. 2-5 loose stools

3. Well-hydrated: Skin and mouth

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SITUATION XIII

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Question 1:

Brachial pulse

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SITUATION XIV

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Question 1:

4 Suction via the nasotracheal route as needed

Risk of the tube going inside the fractured skull

 

SITUATION XV

 

Question 1:

Move the patient to another room (private room or a patient with RSV)

RSV is a contagious disease which the patient with asthma will be at high risk acquiring the disease.

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SITUATION XVI

 

Question 1:

Pull and hold the pinna down and back