Correct Answer: C

Rationale: While pain management is important following a cleft palate repair, it does not typically require immediate attention. Pain can be managed with appropriate analgesics and does not typically present an immediate risk to the patient's health. A patient refusing to ambulate following an appendectomy does not typically require immediate attention. Encouraging mobility is important for recovery, but refusal to ambulate does not present an immediate risk to the patient's health. Frequent swallowing following a tonsillectomy could indicate post-operative bleeding, which requires immediate attention. Post-tonsillectomy hemorrhage can be a life-threatening condition that requires immediate intervention. While pain at the site of an IV infusion should be addressed, it does not typically require immediate attention unless there are signs of infection or infiltration. It does not present an immediate risk to the patient's health.

Correct Answer: D

Rationale: Telling the child what will happen when the abuse is reported is not the first action a nurse should take. It is important to first gather all necessary information and report the suspected abuse to the appropriate authorities. Requesting a social services referral is an important step when abuse is suspected, but it should come after obtaining a detailed history and reporting the suspected abuse. Reporting the suspected abuse to the authorities is crucial when child abuse is suspected. However, it is important to first obtain a detailed history to provide as much information as possible to the authorities. When a nurse notes the presence of bruises on a child's arms and legs, the first action should be to obtain a detailed history. This can provide important context for the bruises and help determine whether they are likely the result of accidental injury or possible abuse.

Correct Answer: D

Rationale: The incubation period for varicella, or chickenpox, is typically longer than 2 to 5 days. It usually ranges from 10 to 21 days. An incubation period of 3 to 4 weeks is within the typical range for varicella. However, the average incubation period is usually around 14 to 16 days. An incubation period of 7 to 10 days is shorter than the typical incubation period for varicella, which is usually around 14 to 16 days. An incubation period of 2 to 3 weeks is within the typical range for varicella. The average incubation period is usually around 14 to 16 days.

Correct Answer: A,B,C

Rationale:
Choice A rationale: Rapid pulse is a common manifestation of hypovolemic shock. When the body experiences a significant loss of fluid, such as in severe burns, the heart rate increases in an attempt to maintain adequate blood flow and oxygen delivery to the body's tissues.
Choice B rationale: Decreased blood pressure is another typical sign of hypovolemic shock. As the body loses fluid, the volume of blood circulating through the body decreases. This drop in blood volume leads to a decrease in blood pressure.
Choice C rationale: Pallor, or paleness of the skin, can occur in hypovolemic shock. This happens because the body prioritizes sending blood to vital organs like the heart and brain, which can result in less blood flow to the skin, causing it to appear pale.
Choice D rationale: A flushed face is not typically associated with hypovolemic shock. In fact, the skin may actually appear pale or cool due to reduced blood flow.

Correct Answer: B

Rationale: Yogurt is not part of a clear liquid diet. It is a dairy product and is not clear or liquid at room temperature. Gelatin is part of a clear liquid diet. This type of diet is often prescribed before medical procedures or tests, or for patients with certain digestive issues. It consists of liquids and foods that are clear and liquid at room temperature. Strained soup might be allowed on a full liquid diet, but it is not part of a clear liquid diet. Only the broth of the soup, which is clear and liquid at room temperature, would be allowed. Pureed fruit is not part of a clear liquid diet. While it is a liquid at room temperature, it is not clear.