A child with sickle cell anemia develops severe chest pain, fever, a cough, and dyspnea. The nurse's first action is to

Correct Answer: C

Rationale: In a child with sickle cell anemia experiencing severe chest pain, fever, cough, and dyspnea, the priority action is to suspect acute chest syndrome, a life-threatening complication. The nurse's first action should be to notify the practitioner for immediate evaluation and intervention. Administering 100% oxygen (Choice A) may be necessary later but is not the initial priority. Administering pain medication (Choice B) should not precede notifying the practitioner, as addressing the underlying cause is crucial. The symptoms described are more indicative of acute chest syndrome than a stroke, so notifying the practitioner for chest syndrome (Choice C) takes precedence over suspecting a stroke (Choice D).

Correct Answer: D

Rationale: In caring for an infant with phenylketonuria (PKU), the nurse should anticipate that the healthcare provider will order a diet that is low in phenylalanine. Phenylalanine is an amino acid that individuals with PKU cannot metabolize properly, leading to a buildup of toxic byproducts. A low-phenylalanine diet is essential to prevent cognitive impairment and other serious complications associated with PKU. Option A, a fat-free diet, is not the correct choice because the focus in PKU management is on restricting phenylalanine, not fat. Option B, a protein-enriched diet, would be contraindicated as protein sources typically contain phenylalanine. Option C, a phenylalanine-free diet, is not feasible as phenylalanine is present in many foods, but a diet low in phenylalanine is achievable and effective. Educationally, understanding the dietary management of PKU is crucial for nurses caring for pediatric patients with this condition. It underscores the importance of strict dietary adherence to prevent the serious consequences of untreated PKU. Nurses play a vital role in educating families on meal planning, monitoring phenylalanine intake, and collaborating with dietitians to ensure optimal nutrition while managing PKU effectively.

Correct Answer: B

Rationale: For a 2-year-old child, the maximum recommended amount of fluid for an isotonic enema is between 155 to 250 mL to prevent overdistension and potential harm. Choice A (100 to 150 mL) is too low and may not be effective in achieving the desired outcome. Choices C (255 to 360 mL) and D (365 to 500 mL) exceed the safe range for a 2-year-old child and can lead to overdistension, electrolyte imbalance, or other complications. Therefore, the correct answer is B.

Correct Answer: A

Rationale: The correct statement should be, 'We should give this drug after he eats something.' Prednisone should be administered with food to help prevent gastrointestinal upset. Choice B is correct as monitoring for infections is important due to prednisone's immunosuppressive effects. Choice C is correct as prednisone should not be stopped suddenly to prevent withdrawal symptoms. Choice D is correct as weight gain is a common side effect of prednisone.

Correct Answer: D

Rationale: After undergoing surgery for pectus excavatum correction with steel bar placement, the nurse should instruct the parents to avoid placing the child in a side-lying position. This position should be avoided to prevent displacement of the steel bar, which could compromise the surgical outcome. Semi-Fowler, supine, and high Fowler positions do not pose the same risk of displacing the steel bar and are generally safe and comfortable for the child in this postoperative period.