Chamberlain College of Nursing - ATI NURSING : ATI Pediatric Test Bank 2, latest 2021 Complete answers PROCTORED

Document Content and Description Below

a nurse is planning to care for a child who has severe diarrhea. Which of the following actions is the nurse's priority? A. Introduce a regular diet B. Rehydrate C. Maintain fluid therapy D. Asse... ss fluid balance (Assess first the other three are interventions, before you intervene you have to assess how much fluid imbalance. Check for lab results because it will tell you what kind of fluid is to be given and how much fluid to be replaced. Priority is assessment first) A nurse is caring for a toddler who’s parent states that the child has a mass in his abdominal area and his urine is a pink color. Which of the following actions is the nurse’s priority? A. Schedule the child for an abdominal ultrasound B. Instruct the parent to avoid pressing on the abdominal area C. Determine if the child is having pain D. Obtain a urine specimen for a urinalysis A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions is the nurse’s priority? A. Place the child on a no salt added diet B. Check the Child's weight daily C. Educate the parents about potential complications D. Maintain a saline lock (IV access that is attached to any fluids. For emergency) (inflammation of the kidneys caused by group A beta hemolytic streptococcus, infection. Fluid or fluid retention. Patients with kidney problems affect blood pressure -> High blood pressure because of fluid retention. Salt increases high blood pressure. Lower the salt intake of this patient) A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following is the nurse’s priority? A. Administer antibiotics when available B. Reduce environmental stimuli (because of increase of ICP and can cause seizures) C. Document intake and output D. Maintain seizure precautions A nurse is collecting data from an adolescent. Which of the following represents the greatest risk for suicide? A. Availability of firearms B. Family conflict C. Homosexuality D. Active psychiatric disorder (Mark, mental problems, patients mind is unstable) A nurse is collecting data from an infant who has otitis media (middle ear infection). The nurse should expect which of the following findings? A. Tugging on the affected ear lobeB. Bluish green discharge from the ear canal (there’s usually no discharge, discharge only comes out if there’s opening in the ear drum) C. Increase in appetite (decrease in appetite) D. Erythema and edema of the affected auricle (usually no redness in the affected auricle) (otitis externa: infection of the outer ear) A nurse is reinforcing teaching with a parent of a 1 month old infant who is to undergo the initial surgery to treat Hirschsprung’s disease (a ganglionic megacolon, part of the colon isn’t connected to the nerves or not functioning, so there will be an increase size of the colon and stool gets stuck in there). Which of the following statements should indicate to the nurse that the parent understands the goal of surgery? A. “I’m glad that the ostomy is only temporary “ (1st there going to cut the nonfunctioning of the colon, and then apply temporary colostomy, after a couple of months they will suture it together) B. “I’m glad my child will have normal bowel movements now” C. “I want to learn how to use the feeding tube as soon as possible” D. “the operation will straighten out the kink in the intestine” A nurse is caring for an infant who is 1 day postoperative following surgical repair of a cleft lip. Which of the following actions should the nurse take? A. Apply an antibiotic ointment to the suture site B. Clear oral secretions using a bulb syringe C. Feed the infant using a spoon D. Position the infant on her abdomen A nurse is reinforcing discharge instructions with a parent of a child who has cystic fibrosis. Which of the following statements by the parent indicates an understanding of the teaching? A. “I will make sure my child washes her hands before eating” B. “I will restrict the amount of salt in my child’s meal” C. “I will put my child in daycare to ensure that she socializes with other children” D. “I will provide low fat meals for my child A nurse working at a clinic speaks on the telephone with a parent of a 2-month old infant. The parent tells the nurse that the infant has projectile vomiting followed by hunger after meals. Which of the following responses by the nurse is appropriate? A. “Bring your infant into the clinic today to be seen” B. “Burp your child more frequently during feedings” C. “Give your infant an oral rehydration solution” D. “You might want to try switching to different formula” A nurse is caring for a 4 year old child who is 2 days postoperative following the insertion of a ventriculoperitoneal shunt. Which of the following findings should the nurse identify as the priority . (causes icp hydrocephalus) A. lethargy (high pitched cry, respiratory changes, bradycardia, wide pulse pressure, irritability) B. lying flat on the unaffected sideC. respiratory rate 20/min D. urine output 50 mL in 2hr A nurse is caring for a child following an open reduction and internal fixation of a fractured femur and application of a cast. The cast has a window cut in it for viewing of the incision. Which of the following actions should the nurse take first? A. Remove the window and view the incision B. Turn the client so the cast will dry on all sides C. Medicate the client for pain D. Perform neurovascular checks of the affected extremity (check for infection, color, capillary refill, redness) A nurse is an urgent care clinic is assisting with the care of a toddler who ingested 30 tablets of aspirin. Which of the following substances should the nurse administer to the toddler? A. Activated charcoal (can work with toxin, poison. Given through ng tube absorbs toxins) B. Acetylcysteine (antidote for acetaminophen) C. A chelating agent (usually used for iron) D. Digoxin immune FAB A nurse is caring for a 3 year old client who has persistent otitis media. To help identify contributing factors, the nurse should ask the parents which of the following questions? A. Has your daughter been drinking 6 glasses of water a day B. Does anyone smoke in the same house as your daughter? (smoking can cause irritation, cause mucus in respiratory and causes otitis media?) (otitis media is purulent color) C. Does your daughter get water in her ears when you bathe her? (otitis externa, bluish green color) D. Has your daughter had a lot of earwax in her ears over the last month? A nurse is collecting data from a 2 year old toddler who has AIDS. The nurse should inspect inside the toddler mouth for which of the following opportunistic infections (fungus infections is usually opportunistic infections)? A. Candidiasis (also called oral thrush) B. Gingivitis C. Canker sores D. Koplik spots (measles, rubella) A nurse is caring for a 4 year old child who has dehydration. Which of the following findings should the nurse identify as the priority? A. Blood glucose 110 mg/dL B. Potassium 2.5 mEq/L C. Sodium 142 mEq/L D. Urine specific gravity 1.025A nurse is caring for a child who Is postoperative following the insertion of a ventriculoperitoneal shunt. The nurse should place the child in which of the following positions? A. On the non operative side B. 45 degree head elevation C. Prone D. Supine A nurse is caring for an infant who is dehydrated and requires IV therapy. The nurse should monitor the infant response to therapy by performing which of the following actions? A. weighing the infants at the same time everyday B. Taking the infants vital signs every 2 hr. C. Measuring the infant's head circumference twice per day D. Counting the number of wet diapers every shift A nurse is caring for a preschool age child who has croup. Which of the following findings should the nurse report to the provider? A. Barky cough B. Paroxysmal attacks of laryngeal spasm at night C. Hoarseness D. Drooling (that could mean it can mean there’s an epiglottitis causes obstruction of the airway) A nurse is collecting data from an infant who has hypertrophic pyloric stenosis. Which of the following findings should the nurse expect? A. Projectile vomiting B. Bile colored vomit C. Absent bowel sounds D. Fever A school nurse is screening an 11-year-old child for idiopathic scoliosis. Which of the following instructions should the nurse give the child for this examination? A. Lie prone on the examination table B. Touch your chin to your chest and then look up at the ceiling C. Turn to the side and remain in a relaxed position D. Bend forward from the waist with your head and arms downward A nurse is collecting data from an infant. Which of the following sites is the most reliable location to check the infant's pulse ? A. Carotid B. Apical C. Dorsalis pedis D. Temporal A nurse is reinforcing teaching with a parent of a child who has eczema. Which of the following instructions should the nurse include in the teachingA. Apply a cool wet compress to the affected area B. Launder clothing with fabric softener C. Give bubble baths every day D. Use a wool gloves in the winter time A nurse is caring for a child who has juvenile rheumatoid arthritis. Which of the following actions should the nurse take? A. Administer opioids on a schedule (Nsaids) B. Encourage the child to take daytime naps C. Apply cool compresses for 20 mins every hour D. Maintain night splints to the affected joint A nurse is reinforcing teaching with a parent of an 8-year-old child who has a fracture of the epiphyseal plate. Which of the following statements should the nurse include in the teaching. A. Fractures in a child take longer to heal than fractures in an adult B. Normal bone growth can be affected by the fracture C. Bone marrow can be lost through the fracture D. Your child will need to increase his calcium intake to 3,000 milligrams daily A nurse is collecting data from an 8 month old infant who has increased intracranial pressure (ICP) . Which of the following manifestations should the nurse expect? A. Insomnia (tired sleepy) B. Bulging fontanel C. Low pitched cry (high pitched) D. Positive babinski reflex A nurse is caring for a school age child who has a fracture to the right femur. Which of the following findings is the nurse's priority? A. 2+ right pedal pulse B. respiratory rate 24/min C. capillary refill less than 2 seconds D. tingling in the right foot A nurse is caring for a child who has atopic dermatitis. Which of the following findings should the nurse expect? A. Nonpruritic erythematous papules B. Rash with thick skin C. Maculopapular lesions between fingers and toes D. Inflamed area with white exudate A nurse is assisting with the care of a school age child who has respiratory failure due to pneumonia. Which of the following positions should the nurse encourage to allow maximal lung expansions? A. ProneB. Supine C. Side lying D. Upright (orthopneic positon, semi fowler, high fowler) A nurse in a provider’s office is reinforcing teaching with a parent of a school age child who has pediculosis capitis. Which of the following instructions should the nurse include in the teaching? A. Wash all bed linens and dry them in a dryer for at least 20 min B. Apply permethrin cream twice daily C. Apply an antifungal treatment ointment once every day D. Ensure that family pets are treated within 10 days A nurse is reinforcing teaching with the mother of an infant who has oral candidiasis and is breastfeeding. Which of the following instructions should the nurse include in the teaching? A. Wash hands prior to each breastfeeding B. Swab the infant's mouth with salt water twice daily C. Change to formula feeding with a bottle D. Hand wash pacifier in warm soapy water each day A nurse is caring for a school age child who has mild persistent asthma. Which of the following findings should the nurse expect? (SATA) A. Symptoms are continuous throughout the day B. Daytime symptoms occur more than twice per week C. Nighttime symptoms occur approximately twice per month D. Minor limitations occur with normal activity E. Peak expiratory flow (PEF) is greater than or equal to 80% of the predicted value A nurse is collecting data from a child who has acute appendicitis. Which of the following findings should the nurse expect? A. WBC 17,000/mm3 B. Left lower quadrant abdominal pain C. Hyperactive bowel sounds D. Bradycardia (tachycardia) A nurse is caring for a toddler who has a cast applied 2 hr ago due to multiple fractures of the right hand of the following findings should the nurse report immediately to the charge nurse? A. The fingers on the right hand have a capillary refill of 4 seconds B. The fingertips of the right hand are swollen and bruised C. The child is not attempting to move her right arm or fingers D. The parents report the child will not keep the arm elevated on the pillow A nurse is collecting data from a 3-year-old child who has acute diarrhea and dehydration. Which of the following findings indicates that oral rehydration therapy has been effective? A. Heart rate 130/min B. respiratory 24/minC. urine specific gravity 1.015 (1.010-1.015) higher urine specific gravity is dehydration D. Capillary refill greater than 3 seconds A nurse is caring for a school age child who has a new plaster cast on her right arm. Which of the following actions should the nurse take? A. Position the casted arm in a dependent position (worsen the edema. Elevate it so there won't be edema, elevate it on a pillow ) B. Place a warm moist heat pack on the cast C. Administer diphenhydramine to relieve itching D. Move the casted arm with a firm grip A nurse is caring for a child who is to receive percussion, vibration, and postural drainage. Which of the following actions should the nurse take first? A. Administer albuterol by nebulizer (open the airway, and loosen the secretions it will be more effective to loosen it up) B. Percuss the upper posterior chest C. Perform vibration while the client exhales slowly through the nose D. Instruct the client to cough A nurse is caring for an infant who has spina bifida. Which of the following actions should the nurse take? A. Feed the infant through an BG tube B. Place the infant in prone position C. Cover the infants lesion with a dry cloth (cover infant with moist sterile cloth) D. Perform range of motion exercises to the infant’s hips A nurse is planning care for a child who has epiglottitis. Which of the following actions should the nurse plan to take? A. Obtain a throat culture B. prepare the child for a neck radiograph C. initiate airborne precaution (droplet) D. visualize the epiglottitis using a tongue depressor (it can stimulate spasm and cause airway obstruction) (manifestation of epiglottitis the patient has drooling) A nurse is caring for a child who is experiencing a seizure. Which of the following Actions should the nurse take? A. Elevate the child's legs on a pillow B. Restrain the childs arm C. Insert a padded tongue blade into the child’s mouth D. Place the child in a side lying position(for aspiration) A nurse is caring for an infant who has gastroesophageal reflux. The nurse should place the infant in which of the following positions after feeding? A. Prone (fundamentals)B. Upright (ATI) C. Left side D. Right side A nurse is contributing to the plan of care for a 2month old infant who has just undergone cleft palate repair. The nurse should contribute which of the following interventions to the clients plan of care? A. Feed the infant half strength formula for the first 48 hr. (NPO, start with clear liquids not half strength formula) B. Remove elbow restraints while the infant is sleeping (do not remove the restraint unattended because when they sleep they can still touch the operative site, u can remove it for a short period of time to just monitor) C. Keep the infant in a side lying position D. Administer pain medication PRN for the first 48 hr. (it should not be PRN it should be scheduled) A nurse is receiving a hand off report for a toddler who has a fractured right femur and is in 90 degree /90 degree traction. The nurse should expect to observe which of the following? A. Skin straps maintaining the affected leg in an extended position B. A skeletal pin in the distal end of the femur C. A padded sling under the knee of the affected leg D. The buttocks elevated slightly off of the bed A nurse is caring for a child who is having a tonic clonic seizure and vomiting. Which of the following action is the nurse priority A. Place a pillow under the child's head B. Move the child into a side lying position C. Remove the child's eyeglasses D. Time the seizure A nurse is caring for a child who has tinea pedis. The child's parents ask the nurse what this infection is commonly called. The nurse should respond with which of the following common names A. Shingles B. Athletic foot C. Fever blisters D. Pinworms A nurse is caring for a 6-month-old infant who is postoperative following a myringotomy. Which of the following pain assessment scales should the nurse use to determine the infant's pain level? A. FLACC B. Oucher C. FACESD. Visual analog scale A nurse is collecting data from a child who has spina bifida occulta. Which of the following findings should the nurse expect? A. Hip dislocation B. Flaccid paralysis of lower extremities C. Hydrocephalus D. Dimple in sacral area A nurse is caring for a 2 week old infant whose mother requests additional information about sudden infant death syndrome (SIDS). Which of the following responses should the nurse make? A. You should place your baby on her back when sleeping to decrease the risk of SIDS B. SIDS is directly correlated to diphtheria, tetanus, and pertussis vaccines C. SIDS rates have been rising over the last 1- years D. Sleep apnea is the main cause of SIDS A nurse is caring for a newly admitted adolescents who has anorexia nervosa. Which of the findings should the nurse expect A. Diarrhea B. Hypertension C. Tachycardia D. Lanugo A nurse is collecting data from a child who has (beta) B-thalassemia. Which of the following findings should the nurse expect? A. Hyperactivity (hypoactivity) B. Increased appetite (decreased appetite) C. Fever D. Flushed of skin (pale skin) A nurse in a clinic is preparing to administer pre-k-kindergarten vaccines to a 5 year old child whose medical record indicates that his immunization are up to date which of the following vaccines should the nurse plan to administer A. Measles, mumps, rubella (MMR) B. Haemophilus influenzae type B HIB C. Pneumococcal conjugate vaccine (PCV) D. Hepatitis B (HBV) A nurse is caring for a toddler who is scheduled to have a lumbar puncture. Which of the following actions should the nurse take? A. Ask another nurse to assist with holding the toddler in a prone position B. Restrain the toddler for 1 hr after the procedure C. Place the toddler in a side lying knee chest positionD. Swaddle the toddler in a warm blanket A nurse is planning to speak to a group of adolescents about toxic shock syndrome (TSS) the nurse includes that TSS is commonly associated with which of the following? A. High absorbency tampons B. Mosquito bites C. International travel D. Multiple sexual partners A nurse is talking with a 13 year old female client who is having her annual health screening visit. Which of the following comments by the client should concern the nurse? A My parents treat me like a baby sometimes B I start taking ibuprofen a few days before my period starts C None of the kids at my school like me and I don’t like them either D There's a pimple on my face and i worry that everyone will notice it A nurse is caring for a 6 month old child. The childs provider has ordered a diphtheria, tetanus, and pertussis (DTAP) vaccine to be administered. Which of the following should cause the nurse to question the administration of this vaccine? A. Febrile otitis media B. Evidence of sensitivity to egg antigens C. Temp of 40.5 C (104.9F) after last DTAP D. New onset of seizure disorder in the child's sibling A nurse is caring for an adolescent. The nurse should expect that the adolescent is working on which of the following developmental tasks? A. Building a sense of trust (infant)trust vs mistrust B. Learning to use creative energies (school aged) C. Learning to perform tasks independently (toddler)autonomy vs shame and doubt D. Defining a sense of self (Adolescence) A nurse is selecting a toy for a 7 month old infant. Which of the following toys should the nurse choose? A. A set of blocks to build a block tower B. A colorful crib mobile that plays music C. A soft toy that squeaks or crackles when squeezed D. A wooden farm animal puzzle with large pieces A nurse is reinforcing teaching with the parents of an 8 month old infant who will be admitted for surgery. Which of the following instructions should the nurse include in the teaching? A. You will need to go home when it is not visiting hours B. You should bring the infant's favorite blanket to the hospital C. You should begin to manipulate the infants bedtime based on the hospital visiting hours D. You should read the childs a story about hospitalizationA nurse is collecting data regarding the pain level of a 3 year old child on the second postoperative day following an appendectomy. Which of the following actions should the nurse take? A. Use a numeric scale to assess the child's pain level B. Use the FACES scale to assess the child's pain level C. Use a color tool to assess the child's pain level D. Use the visual analog scale to assess the child's pain level A nurse in a pediatric clinic is collecting data from a preschool age child who has suspected impetigo contagiosa. Which of the following manifestations should the nurse expect to find with this skin infection? A. Scaly patches that have clear centers (ring worm) B. Red macule with honey colored crusts C. Firm brown papules with a roughened, finely papillomatous texture D. Reddened areas with white exudate A nurse is reinforcing teaching with an adolescent regarding administration of the Gardasil vaccine. The vaccine provides Immunity against which of the following sexually transmitted infections? A. Human papillomavirus (HPS) B. Herpes simplex virus ( HSV-2) C. Chlamydia trachomatis D. Gonorrhea A nurse is collecting data from a 7 month old infant. Which of the following findings should indicate to the nurse a need for further evaluation? A. Uses a unidextrous grasp B. Has a fear of strangers C. Sits leaning forward on both hands D. Babbles one syllable sounds A nurse is collecting data from a child who is postoperative following a tonsillectomy. Which of the following is a clinical manifestation of hemorrhage? A. Increased pain B. Poor fluid intake C. Drooling D. Continuous swallowing A nurse is assisting with the admission of a child who has pertussis. Which of the following actions should the nurse take? A. Initiate a protective environment B. Initiate airborne precautions C. Initiate droplet precautionsD. Initiate contact precautions A nurse is caring for a child who has erythema infection. Which of the following findings should the nurse expect? A. Facial erythema B. Koplik spots (measles) C. Parotitis (mumps) D. Pruritus (itchiness. Chicken pox) A nurse is collecting data from an infant who has developmental dysplasia of the hip (DDH) . Which of the following findings should the nurse expect? A. Absent plantar reflexes B. Lengthened thigh on the affected side C. Inwardly turned foot on the affected side D. Asymmetric thigh folds A nurse is caring for a child who has nosebleed. Which of the following actions should the nurse take? A. Place the child in a sitting position and tilt her head back B. Apply ice at the opening of the nares for 5 min and then recheck for bleeding C. Place the child In a supine position with a pillow under her head D. Have the child sit with her head tilted forward and hold pressure on her nose for 10 mins (use ur fingers pinching the nose) A nurse is collecting data from a 1 year old child who has Wilms tumor. Which of the following findings should the nurse expect? A. Jaundice B. Swollen joints C. Abdominal mass D. Diarrhea A nurse is caring for a school age child who has acute glomerulonephritis. The child has peripheral edema and is producing 35mL of urine per hour. Which of the following diets should the nurse anticipate the provider will prescribe? A. Low sodium, fluid restricted B. Regular diet no added salt C. Low carbohydrate, D. low protein diet A nurse is preparing to administer vaccines to a 4 month old infant. Which of the following vaccines should the nurse administer? A. Rotavirus B. InfluenzaC. MMR (measles, mumps, rubella) D. Varicella (VAR) A nurse is collecting data from an infant at well-child visit. The nurse should expect the infant to double his birth weight by which of the following ages? A. 3 months B. 6 months C. 9 months D. 12 months Nurse is caring for a child who reports being physically abused by a family member. Which of the following statements should the nurse make? A. I promise I wont tell anyone about this B. Lets discuss what you have told me with your family members C. Your family is bad for doing this to you D. it is not your fault that this happened A nurse is preparing to administer immunizations to a child who has an allergy to eggs. The nurse should know that an allergy to eggs is a contraindication for which of the following immunizations ? A Influenza (TIV) B Inactivated poliovirus (IPV) C Haemophilus Influenza tybe B (HiB) D Hepatitis B (Hep B) A nurse on a medical-surgical unit is caring for a group of children. Which of the following findings should alert the nurse that one of the children is a potential victim of abuse? A. A toddler who has multiple Bruises on the shins of both legs and his parents report that he is clumsy. B. A preschooler who has a BMI indicating Obesity. C. A school age child who cries when the nurse is giving him an injection D. An adolescent who asks to stay in the hospital because he likes the room A nurse is preparing to administer IM injection to a preschool-age child. Which of the following actions should the nurse take? A. Ask the parents to hold the child B. Allow the child to hold a favorite toy. C. Administer the medication in the child’s room D. Tell the child the medicine will make him feel better. A nurse is contributing to the plan of care of an unconscious adolescent who ingested a non corrosive substance that has no recommended antidote. The nurse should recommend to perform gastric lavage with which of the following substances? A. 0.9% sodium chlorideB. Syrup of Ipecac C. Osmotic Diarrheal agents D. Activated Charcoal (absorbs toxins in the stomach, Mixed with Saline for aspiration via NG tube ) A nurse is reinforcing teaching about preventing disease transmission with the parents of a child who has a streptococcal infection. Which of the following instructions should the nurse include? A. Ill continue to encourage him to drink lots of fluids.” B. Ill take his temp. Q 4 hours” C. Ill give him acetaminophen for the pain D. Ill discard his toothbrush and buy another A nurse on a pediatric unit is caring for a client who has a brain tumor. To help ensure the client’s safety, which of the following actions should the nurse take? A. Do not allow the child to ambulate in his room alone. B. Limit contact with other pediatric clients. C. Initiate Seizure precautions for the child D. Have the child use a wheelchair for all out-of-bed activities A nurse is caring for a child who is having a seizure. Which of the following actions should the nurse take (SATA) A loosen restrictive clothing B place a tongue depressor in the child’s mouth C clear the area of hard objects D Place the child in prone positions E Restrain the child A nurse enters a school age child’s room to administer morning medications and finds the client sitting in a chair having a seizure. - After lowering the client to the floor Lateral position A nurse is assisting with the care of a child with spina bifida. Which of the following precautions should nurse take while caring for this child? - Precautions for Spina Bifida -- Latex Precautions A nurse is assisting with the admission of an infant who has resp. Syncytial Virus (RSV) which of the following rooms should the nurse assign the infant? A. A semi-private room with an infant who has a croup B. A semi-private room with a toddler who has pneumonia C. A private room with contact/droplet precautions D. A private room with protective isolationA nurse is caring for an adolescent client who is receiving carbamazepine for partial seizure disorder. Which of the following statements by the adolescent parent is the priority for the nurse to address?” A. He only sleeps 5 hours each night B. HE takes his medication between meals with water C. He seems to be getting a lot more bumps and bruises lately D. HE has not been eating as much lately” A nurse is caring for a toddler who has laryngotracheobronchitis ( LTB ) For which of the following findings should the nurse monitor to detect airway obstruction? A. Decreased Stridor (increase airway becomes more obstructive) B. Decreased Restlessness ( increase ) C. Increased Heart rate ( in order to deliver more blood pump more oxygen ) D. Decreased Temperature ( Increased Temperature ) A nurse is reinforcing teaching with the mother of a 2-month old infant whose provider applied a Pavlik Harness 1 week earlier for the treatment of developmental hip dysplasia. Which of the following statements. Which of the following statements by the mother indicates an understanding of the teaching? A. I will adjust the harness straps every day.” B. I will place the diaper over the harness.” ( Under the Harness ) C. I will check my baby’s skin three times each day. D. I will gently massage lotion on his skin around the harness clasps.” (Build up in skin and cause irritation ) A nurse reinforcing teaching with the parents of a school-age child who has cystic fibrosis. Which of the following statements should the nurse make? A administer a bronchodilator to the child after chest percussion therapy .” B. a pigeon- shaped chase might become evident as the disease progresses. “ C. Bradycardia is an early indicator of pneumothorax.” D. Engage the child in daily aerobic exercise. “(help promote erection of the mucus. Endorphine will Rise. YEEEE) A nurse is a collecting data from an infant which of the following is a clinical manifestation of pyloric stenosis?” A. Absent Bowel sounds (appendicitis and hirschsprung disease) B. Increased Sodium Level (decrease because of vomiting) C. Projectile Vomiting after feedings D. Golf- ball size over the left quadrant (olive shaped mass) (On the right of Umbilicus ) A nurse is planning meals for a 2-year child who has a fractured jaw and is having difficulty swallowing. The surgeon has prescribed a pureed diet. Which of the following food selections should the nurse make? A. scrambled egg (Pureed)B. Cottage Cheese (mechanical diet) C. Dried fruit D. Peas A nurse reinforcing teaching the parents of a preschooler who has a atopic dermatitis. Which of the following information should the nurse include? A. You’ll need to take the entire prescription of antibiotics even if your symptoms improve. B. The doctors may recommend antihistamines to help control symptoms. C. You can relieve your child’s discomfort by applying warm compression of the lesion. D.The doctor will remove the lesions with the liquid nitrogen A nurse is contributing to the plan of care of a 14-month old toddler who is 24 hour post-OP following a cleft palate repair. Which of the following interventions should the nurse include in the plan? A. Provide soft foods for the toddler. B. Suction the toddler nose and mouth every hour C. Maintain elbow restraints on the toddler D. Give the toddler a hard – tipped sippy cup to drink liquids. A nurse is collecting data from an infant who has Gastroesophageal reflux (GERD) . Which of the following findings should the nurse expect? (SATA) A. Vomiting B. Weight Loss C. Rigid Abdomen ( for Appendecitis ) D. Wheezing E. Pallor A nurse is caring for a toddler who has intussusception. Which of the following manifestations should the nurse expect? A. Drooping B. Increased Appetite C. Jaundice D. Mucus in Stools A nurse is caring for a 4-year old child who refuses to take his medication because of the bad taste. Which of the following strategies should the nurse use to medication A. Offer the child an ice pop prior to administering the medication ( numb the tongue …Nerves ) B. Tell the child the medicine tastes like candy C. Hide the medication in apple slices. D. Inform the child that if he does not take the medication he will need a shot. A nurse is reviewing the medical record of an adolescent and notes a calcium level of 11.5 mEq/L Which of the following findings should the nurse expect? ( 9- 10.5 = Normal Calcium level )A. Diarrhea B. Muscle Hypotonicity C. Tachycardia ( HypoCalcemia ) D. Positive Chvostek’s sign ( HypoCalcemia) (Face twitching after a tap ) tappity tap A nurse is planning care for a 4-year old child who has been admitted to the hospital. Which of the following toys. Should the nurse plan to provide the child? A. Modeling Clay B. Brightly Colored mobile ( INFANTS ) C. 100- piece jigsaw puzzle ( TOO MUCH APPARENTLY ) D. Checkerboard and Checkers ( SCHOOL AGE 6-12 Y/O ) A nurse is reinforcing teaching about elimination with an adolescent who is paralyzed from the waist down following a spinal cord injury. Which of the following statements by the adolescent indicates a need for further teaching ? A. “ I need to catheterize myself twice a day. “ ( Catheterize every 4-6 Hours ) B. I carry a water bottle with me because I drink a lot of water.” C. I used a suppository every night to have bowel movements .” D. I do my wheelchair exercises sitting in my chair A parent asks a nurse about toys to provide for a 10-month old infant. Which of the following toys should the nurse suggest? A. Push- Pull Toy B. Crib Gym C. Large-Piece puzzles D. Coloring book with crayons A guardian calls the clinic nurse after his child has developed symptoms of varicella and asks when his child will no longer be contagious. Which of the following responses should the nurse make? a) “When your child no longer has a fever.” b) “Three days after the rash started.” c) “Six days after lesions appear if they are crusted.” (The nurse should inform the guardian that a child will stop being contagious around 6 days after the lesions appeared, as long as they are crusted over.) d) “When your child’s lesions disappear.” A nurse is reinforcing teaching about sudden infant death syndrome (SIDS) with the parent of a 1-month-old infant. Which of the following statements by the parent indicates an understanding of the teaching? a) “I will let my baby sleep with me in bed at night.” b) “I will allow my baby to have a pacifier while sleeping.” (The nurse should reinforce with the parent that allowing the infant to fall asleep with a pacifier in his mouth decreases the risk for SIDS.)c) “I will place my baby on a soft mattress to sleep.” d) “I will cover my baby with a quilt while he is sleeping.” A nurse is collecting data from a school-age child. The nurse should identify which of the following findings is a manifestation of physical abuse? a) Multiple dental caries b) Malnutrition c) Recurrent urinary tract infections d) Bruises at various stages of healing (The nurse should recognize that bruises at various stages of healing are a clinical manifestation of physical abuse.) A nurse is reinforcing teaching with an adolescent who has an inflamed non perforated appendix and is scheduled for a laparoscopic assisted appendectomy. Which of the following instructions should the nurse include in the teaching? a) “You can begin drinking fluids again 2 days after your surgery.” b) “You will need to ask for pain medication for the first 24 hours after surgery.” c) “You will have your vital signs monitored every 8 hours after surgery.” d) “You will sit in your chair at least twice a day after surgery.” (The nurse should instruct the client that she will sit in a bedside chair at least twice a day and will be encouraged to ambulate as soon as possible following surgery. This activity will enhance lung function and help prevent postoperative complications.) A nurse is assisting with the care of a child who is postoperative and received a transfusion during a surgical procedure. Which of the following findings indicates the child is having a hemolytic reaction? a) Chills and flank pain (Chills and flank pain are findings that indicate an incompatibility of the transfused blood product with the client's blood. The nurse should identify this finding as an indication that the child is having a hemolytic reaction.) b) Pruritus and flushing c) Rales and cyanosis d) Bradycardia and diarrhea A nurse is collecting date from a child during a well-child visit. The nurse should recognize that which of the following findings places the child at a higher risk for abuse? a) The child is 6 years old. b) The child is male. c) The child was born at 30 weeks of gestation. (The nurse should identify that children who are born prematurely are at greater risk for abuse because of the potential for impaired bonding during early infancy.) d) The child was born via cesarean birth.A nurse is reinforcing teaching with the guardian of a child who has a new diagnosis of rheumatic fever. Which of the following statements by the guardian indicates an understanding of the teaching? a) “I should not give my child aspirin for pain or fever.” b) “My child will take antibiotics for 6 months.” c) “My child might have a period of irregular movement of the extremities.” (The nurse should instruct the guardian that the child might experience chorea weeks or months after the initial diagnosis. Chorea is a temporary lack of coordination and the presence of sudden, irregular movements or periods of clumsiness.) d) “I should expect there to be blood in my child’s urine.” A nurse is collecting data from an infant during a well-child visit. Which of the following sites should the nurse use when obtaining the infant’s heart rate? a) Apical (The nurse should use the apical pulse to obtain the infant's heart rate and count it for a full minute, because it gives a reliable rate and rhythm and provides accurate baseline assessment data. In an infant, the apical heart rate is auscultated at the fourth intercostal space lateral to the midclavicular line.) b) Radial c) Carotid d) Femoral A nurse is preparing a toddler for suturing of a minor facial laceration. The nurse should place the toddler in which of the following restraints? a) Mummy restraint (The nurse should use a mummy wrap when a short-term restraint is needed for treatment of the toddler that involves the head and neck. The nurse should always use the least amount of restraint necessary.) b) Jacket restraint c) Elbow restraint d) Wrist restraint A nurse is reinforcing dietary teaching with the parent of a 2-year-old toddler. Which of the following should the nurse include in the teaching? a) "It is recommended that the toddler consumes no more than 12 ounces of fruit juice each day." b) "An appropriate serving size is 1 tablespoon of food per year of age." (The nurse should include that an appropriate serving size for a 2-year-old toddler is 1 tbsp of food per year of age.) c) "Introduce healthy finger foods like carrots and celery sticks." d) "Encourage 5 cups of low-fat milk each day." Hospice nurse is conducting a support group for parents of toddlers who have a terminal illness. Which of the following pieces of information should the nurse include in the teaching? - Toddlers will react to parents’ anxiety and sadnessNurse is creating a plan of care for a 6-month old infant who requires continuous pulse oximetry monitoring. Which of the following interventions should the nurse include? - Cover the oximetry sensor with clothing Nurse is assessing a 3 year old child who is 1 day postoperative following a tonsillectomy. Which of the following methods should the nurse use to determine if the child is experiencing pain? - Use the FACES scale Nurse is caring for a child with a vesicular rash that has been present for 6 days. The nurse should expect that the child has which of the following conditions? - Varicella Nurse is planning care for a 6 year old child who is receiving chemotherapy. The child has a highlight platelet count of 20,000.mm^3. Based on this laboratory value, which of the following interventions should the nurse include in the plan of care? - Encourage quiet play Nurse is caring for a child who has tetralogy of fallot. Which of the following laboratory values should the nurse expect to find? - RBC 6.8 million/uL Nurse is providing teaching about foods high in fiber to the guardian of a child who has chronic constipation. Which of the following foods should the nurse recommend? - ½ cup of cooked pinto beans (high fiber) Nurse is teaching parents of a 3 year old child who has persistent otitis media about prevention. Which of the following statements by the parents indicates an understanding of the teaching? - We should not smoke around our child Nurse is teaching the parents of a child who has cerebral palsy. Which of the following statements should the nurse make? - Your child will need a botulinum toxic A injection to reduce muscle spasticity. Nurse is caring for an infant who has a tracheoesophageal fistula. Which of the following actions should the nurse take? - Perform oropharyngeal suctioning Nurse is teaching the parent of a 12- month old infant about nutrition. Which of the following statements by the parent indicates a need for further teaching? - My infant drinks at least 2 qt of skin milk each dayNurse is caring for a child who received penicillin IM 15 minutes ago. The child is now irritable and restless. Which of the following actions should the nurse take first? - Assess for laryngeal edema Nurse is assessing a 1 week old infant at a well-child visit. The nurse should notify the provider about which of the following assessment findings? - Blue coloring of the sclera Nurse receives laboratory results for several clients. Which of the following results should the nurse report to the provider? - A client who has DKA and a blood glucose of 375 mg/dl (blood glucose goal should be below 240 mg/dL) Nurse is caring for an infant who has biliary atresia. Which of the following manifestations should the nurse expect? (SATA) -Yellow sclera - abdominal distension - dark urine Nurse is assessing an infant who was born at 32 weeks gestation and is now 8 months old. Which of the following developmental ages should the nurse expect the infant to demonstrate? - 6 months Nurse is caring for an adolescent who has sickle cell anemia., which of the following manifestations are the result of chronic vaso-occlusive phenomena? (SATA) - Enlarged heart - Enuresis - Leg ulcers - Retinal detachment During a well-child visit, the guardian of a toddler reports that the toddler takes several hours to fall asleep at night. Which of the following recommendations should the nurse make? - Provide the toddler with a favorite stuffed animal at bedtime Nurse is teaching a parent of an infant who has a colostomy. Which of the following statements by the parent indicates an understanding of the teaching? - I need to apply paste to the back of the wafer on my child’s appliance Nurse is teaching the parent of a child who has type 1 diabetes mellitus on how to manage the child’s disorder during an illness such as a cold. Which of the following statements by the parent indicates an understanding of the teaching? - Ill check his blood glucose more oftenNurse is assessing the fine motor skills of a 3 year old preschooler. Which of the following findings should the nurse expect? - BUilds a tower of 9 cubes Nurse is caring for a child who has autism spectrum disorder. Which of the follwing actions should the nurse take? - Ensure that staff visits with the child are kept short Nurse is creating a plan of care for a preschooler who was admitted for the treatment of measles. Which of the following activities should the nurse include in the client’s care plan? - Putting together a puzzle with large pieces Nurse is caring for a child with cystic fibrosis who has a pulmonary infection. Which of the following findings is the nurse’s priority? - Inability to clear secretions Nurse is preparing to feed an infant who has a cleft lip and palate. Which of the following actions should the nurse plan to take? - Burp the infant at least 2-3 times during the feeding Nurse is caring for a school aged child who has sickle cell anemia. Which of the following actions should the nurse plan to take to help decrease the risk of a vaso-occlusive crisis? - Provide adequate fluid intake throughout the day Nurse is assessing a 30-month-old toddler during a well-child visit. Which of the following findings requires further assessment by the nurse? - The toddler’s birth weight is tripled. Nurse in the emergency department is assessing a preschooler for indications of child maltreatment. The nurse should identify which of the following findings is a manifestation of physical abuse? - Bruises at various stages of healing Nurse is assessing a 6-month old infant who was recently admitted with acute vomiting and diarrhea. Which of the following findings indicates the infant has moderate dehydration? - Tachypnea Nurse is assessing a 4-year old child for growth and developmental milestones during a well-child visit. Which of the following findings suggests a possible delay in development? - Speaking using 2-3 word sentencesNurse is preparing to assess an 11-month-old infant during a well-child examination. Which of the following actions should the nurse take? - Examine the infant’s throat at the end of the examination Nurse in an emergency department is caring for a toddler who is in acute respiratory distress. Which of the following findings should alert the nurse to the possibility of epiglottis? - Drooling Nurse is reviewing the laboratory result of a child who has experienced diarrhea for the past 24 hr. Which of the following values for urine specific gravity should the nurse expect? - 1.035 Nurse is teaching the guardian of an 18-month-old toddler about otic medication administration. Which of the following statements should the nurse make? - Gently pull the ear cartilage down and back when administering the medication Nurse is teaching the parent of a 3-year-old toddler about promoting sleep. Which of the following pieces of information should the nurse include? - Follow a nightly routine and established bedtime Nurse is caring for a school-age child who has glomerulonephritis. The child has decreased urinary output and a blood pressure of 160/78, and is receiving hydralazine. Which of the following lunch choices should the nurse recommend? - 3 oz grilled chicken, 1 cup of pear slices, and 120 mL (4 oz ) of apple juice Nurse is planning care for a 3-month-old infant who has an ileostomy. Which of the following interventions should the nurse include in the plan? - Check the bag for stool every 4 hr Nurse is providing teaching to a parent of a preschooler who has impetigo. Which of the following statements by the parent indicates an understanding of the teaching? - I will wash my child’s clothes in hot water Nurse is providing postoperative teaching to the parent of a 3-month-old infant who is recovering from an umbilical hernia repair. Which of the following statements by the parent indicates an understanding of the teaching? - I will fold my baby;s diaper away from the incision Nurse is performing a developmental assessment on a 3-year-old child. Which of the following commands should the nurse expect the child to complete successfully? - Put your shoes onNurse is caring for a 3-year-old child who has a cyanotic cardiac defect. The child cries when her parents leave the room, worsening her cyanosis and dyspnea. Into which of the following positions should the nurse place the child to improve these manifestations? - Knee-chest Nurse is providing teaching about disease management to the parent of a preschooler who has a new diagnosis of asthma. Which of the following parent statements indicates an understanding of the teaching? - I will encourage my child to participate in sports Nurse is teaching the parent of a school-age child who has celiac disease. Which of the following foods selected by the parent indicates an understanding of the teaching? - Corn tortilla with black beans Nurse is providing discharge teaching to the parents of a child who has nephrotic syndrome. Which of the following instructions should the nurse include in the teaching? - Keep the child away from people who have an infection Nurse is providing teaching to the guardians of a 4-month-old infant on how to play with the infant. Which of the following play activities should the nurse suggest for this infant? - Allow the infant to splash in the bathtub Nurse is helping the parents of a child who is terminally ill to prepare for the impending loss of their child. Which of the following statements should the nurse make? - Would you like assistance in planning where your child will die? Nurse is providing teaching to parents of a school-aged child who has type 1 diabetes mellitus about managing hypoglycemia. Which of the following responses by a parent indicates an understanding of the teaching? - I will make sure my child drinks 240ml (8 oz) of milk as soon as possible Nurse is caring for a 4-month-old child who has acute otitis media and a fever of 38.3 C. which of the following medications should the nurse administer? - Amoxicillin Nurse is reviewing the medical record of a 2-month old infant who has rotavirus. The nurse notes a hemoglobin level of 12 g/dL and a hematocrit of 51%. Which of the following statements by the nurse indicates an understanding of the laboratory values? - The infant might be dehydrated Nurse is providing teaching to the guardians of an infant who has failure to thrive (FTT). which of the following pieces of information should the nurse include in the teaching? - Add fortified rice cereal to the infant’s formulaWhich of the following behaviors should the nurse identify as an expected achievement for a 3 year old child? - Standing on 1 foot for several seconds Nurse is assessing a school age child who has celiac disease. Which of the following findings should the nurse expect? - Steathorrhea Nurse in an emergency department is assisting with the care of a 4-year old child who ingested toilet bowl cleaner. The child has hemoptysis, is crying and states, “it burns”. Which of the following actions should the nurse perform? (SATA) - Identify how much cleaner was in the bottle - Insert an IV for morphine administration - Apply a pulse oximeter Nurse is assessing a child who has been stung by a bee. The child’s hand is swelling , and the nurse notes the the child is allergic to insect stings. Which of the following findings should the nurse expect if the child develops anaphylaxis? (SATA) - Nausea - Urticaria - Stridor Nurse is caring for an infant who is 6 months old and has moderate dehydration. Which of the following findings should the nurse expect? - Dry mucous membranes Nurse is caring for a female adolescent who is being treated for frequent urinary tract infections (UTI). Which of the following statements by the adolescent indicates a possible cause of the UTI? - I have a bowel movements every 4-5 days Nurse is providing teaching to an adolescent who has fiberglass arm cast. Which of the following instructions should the nurse include in the teaching? - Place a plastic bag over the cast when showering Nurse is teaching a school age child who has a new diagnosis of type 1 diabetes. Which of the following statements should the nurse make? - You can use a vial of insulin up to 30 days Nurse providing discharge teaching to parents of school aged child who has leukemia and is receiving chemotherapy. Which of the following statements by the parent indicates an understanding of the teaching? - I will inspect my child’s mouth everyday for soresNurse is teaching a newly hired nurse about aring for an infant who is postoperative following myelomeningocele repair. The nurse should teach the newly hired nurse to monitor the infant for which of the following complications? - Hydrocephalus Nurse is planning care for a 4-year-old child who has nephrotic syndrome. Which of the following actions should the nurse take? - Provide thorough skin care Nurse is teaching a parent of a 12-month-old infant about development during the toddler years. Which of the following statements should the nurse include? - Your child should be able to scribble spontaneously using a crayon at 15 months of age Nurse is providing education for the family of a 6-month-old infant about ways to stimulate language development. Which of the following instructions should the nurse include? - Explain what you are doing to the infant while providing care Nurse is assessing a child who sustained a head injury. During assessment, the nurse observes clear drainage leaking from the child’s nose. Which of the following actions should the nurse take? - Test the nasal secretions for glucose Contraindication for breastfeeding if infant has - Galactosemia Nurse is caring for a 12-month-old infant following the surgical repair of a cleft palate. The nurse should plan to feed the infant using which of the following instruments? - Cup Nurse is caring for a 4-year-old child who has superficial partial-thickness burns over 50% of his body. To meet the nutritional needs of the child, which of the following actions should the nurse plan to take? - Supplement the child’s feedings with enteral feedings Nurse is providing teaching to the parents of a child who has strabismus, which of the following instructions should the nurse include to prevent the development of amblyopia? - Patch the unaffected eye Nurse is teaching the guardians of a toddler who has a new prescription for an oral iron supplement. To increase the child’s absorption of the iron, the nurse should recommend administering the supplement with which of the following? - Orange juiceNurse is providing teaching for a 14-year old client who has acne. Which of the following instructions should the nurse include? - Keep hair off your forehead Nurse is teaching an adolescent who has asthma about how to use a peak expiratory flow meter (PEFM). Which of the following responsis by the adolescent indicates an understanding of the teaching? - I will record the highest reading of three attempts Nurse is providing discharge teaching to the guardian of an adolescent who is postoperative following a tonsillectomy. Which of the following manifestations should the guardian report to the provider? - Constant clearing of the throat. Nurse teaching parents of a toddler who has enterobiasis about managing this parasitic disease. Which of the following pieces of information should the nurse include in the teaching? - You should keep your child’s fingernails trimmed short Nurse is planning to use guided imagery for an early school aged child who continues to have mild discomfort following the administration of an analgesic. Which of the following techniques should the nurse plan to use? - Encourage the child to focus on a recent pleasurable experience Nurse is caring for a school-aged child who has sickle cell anemia and was admitted for a vaso-occlusive crisis. Which of the following findings should the nurse report to the provider immediately? - Slurred speech Nurse is assessing a 6 month old infant who had a cardiac catheterization with right remoral entry to diagnose a possible congenital heart defect. Which of the following findings should the nurse report to the provider? - Cool toes on the right foot Nurse is providing teaching to the parent of a toddler who has bacterial conjuctivitis. Which of the following instructions should the nurse include? - Notify the provider immediately if the sclera becomes inflamed Nurse is providing education about the introduction of solid foods for the parent of an infant. Which of the following instructions should the nurse include? - Begin after the extrusion reflex has diminished Nurse is assessing an infant who is at risk for increased intracranial pressure (ICP). which of the following findings should indicate to the nurse that this complication is developing? - High pitched cryNurse is performing a visual acuity screening for a school-aged child using the snellen letter chart. Which of the following actions should the nurse take? - Have the child wear his glasses during the vision screening School nurse is assessing an adolescent who returned to school following a case of mononucleosis. The child has a note from his provider excusing him from gym class. Which of the following findings should the nurse identify as the reason for this excusal? - Potential for sustaining abdominal trauma Nurse is admitting a child who has a UTI and a history of myelomeningocele. After completing the admission history, which of the following actions should the nurse plan to take? - Attach a latex allergy alert ID band Nurse providing teaching about home care to the parents of an infant who has diaper dermatitis. Which of the following instructions should the nurse include? - Leave the zinc oxide ointment intact and reapply as necessary during diaper changes. Nurse is planning care for a 10 month old infant who has suspected failure to thrive (FTT). Which of the following intervention should the nurse include in the plan of care? (SATA) - Observe the parents’ actions when feeding the child - Maintain a detailed record of food and fluid intake Nurse is providing teaching about home care to the parent of a child who has a newly applied fiberglass leg cast. Which of the following statements should the nurse include? - Monitor the color of your child’s toes every 4 hours for 24 hours Nurse in an emergency department is assessing a school-aged child who is experiencing an acute asthma exacerbation. Which of the following findings is the priority for the nurse to report to the provider? - Sudden decrease in wheezing Nurse Is providing teaching about oxycodone to an adolescent who is experiencing a vaso-occlusive crisis. Which of the following pieces of information should the nurse include? - The medication might cause nausea Nurse is assessing an infant who has laryngotracheobronchitis. Which of the following findings should the nurse report as an indication of impending airway obstruction? - Nasal flaring Nurse assessing a 2 month old infant who has a ventricular septal defect. Which of the following findings should the nurse report to the provider? - Weight gain of 1.8 kg (4lb)Nurse is providing teaching about immunization to the parents of a severely immunocompromised child who has human immunodeficiency virus (HIV). which of the following statements should the nurse include in the teaching? - The pneumococcal and influenza vaccines are recommended for your child Nurse is assessing an infant who recently started taking digoxin to treat a supraventricular arrhythmia. Which of the following findings should the nurse identify as an indication of digoxin toxicity? - Vomiting Nurse is assessing a 9 month old infant. Which of the following findings should the nurse report to the provider as a possible developmental delay? - Dropping a cube when passing from 1 hand to the other Nurse is caring for a child who has paralytic poliomyelitis. Which of the following actions should the nurse take? - Administer oral analgesics prior to exercises Nurse is teaching an adolescent about managing asthma and using a peak expiratory flow meter. Which of the following statements by the client demonstrates an understanding of the teaching? - I will continue to take my medication when my peak flow rate is in the green zone Nurse is providing teaching to a school-aged child who just had a fiberglass cast application following a lower-extremity fracture. Which of the following instructions should the nurse give the child and his parents about care during the first 48 hr? - Keep the cast above the level of your heart Nurse is performing an annual physical assessment of a preschooler. The parent expresses concern about the child’s 1.8 kg (4 lb) weight gain over the past year. Which of the following responses should the nurse make? - Your child’s weight change is expected for this age group Nurse is assessing a 5-month old infant during a well-child visit. Which of the following findings should the nurse report to the provider? - Head lagging when the infant is pulled from a lying to a sitting position A nurse is caring for a child who has an exacerbation of cystic fibrosis. Which of the following laboratory findings should the nurse report to the provider immediately? - Oxygen saturation 85% Nurse is planning to assess an 8 year old child who was brought to the clinic by parents. The parent reports the child has missed school for 3 weeks and refuses to go back due to “notfeeling well”. Which of the following actions should the nurse perform during the initial interview with the child? - Ask the child to describe what things were like right before not wanting to go to school Nurse is assessing the vital signs of a 1 month old infant. Which of the following actions should the nurse perform? - Count respirations before taking other vital signs Acute lymphocytic leukemia expected laboratory values - Low RBC Nurse is planning to implement relaxation strategies with a young child prior to a painful procedure. Which of the following actions should the nurse take - Rock the child using long, rhythmic movements Nurse caring for a toddler who has gastroenteritis caused by salmonella. Which of the following is the priority action for the nurse? - Initiate contact precautions Nurse is providing anticipatory nutritional guidance for the caregivers of a 5 month old infant. Which of the following points should the nurse include in the teaching? - Allow the infant to try finger foods, such as cracker, after 6 months of age A nurse is caring for a preschooler who has a terminal illness. The nurse should expect the preschooler to have which of the following perspectives about death? - Believes that her own thoughts can cause death Nurse is preparing to assess a 3 month old infant during a well child visit. Which of the following observations should the nurse expect? - The infant looks at his hands Nurse is teaching the parents of a toddler who had an anaphylactic reaction to peanut butter about administering injectable epinephrine. Which of the following instructions hsoudl the nurse include? - You will need to increase the dosage as your child gains weight Nurse is caring for an infant who has tetralogy of fallot and is experiencing a hypercyanotic episode. Which of the following actions should the nurse take? - Place the infant in a knee-chest position Nurse is preparing to administer immunizations to a 5 year old child. Which of the following immunization should the nurse plan to give? - DTaPNurse is providing preoperative education for an 8 year old child prior to cardiac surgery. Which of the following actions should the nurse take? - Use a doll with tubes and an incision to explain the surgery Nurse is assessing a toddler who has measles. Which of the following findings should the nurse expect? - Koplik spots Nurse is teaching the parents of an infant abou treatment options for profound sensoneural hearing loss. The nurse should include which of the following pieces of information about the function of cochlear implants? - They provide direct stimulation of auditory nerve fiber Nurse is caring for a school age child who has skeletal traction applied to repair a pelvic fracture. Which of the following actions should the nurse take? - Place the child on a pressure-reduction mattress Nurse is talking with the parent of a 4 month old infant about growth and development. Which of the following statements indicates the the parent needs further teaching? - My baby loves to play with the pillows in her crib Nurse is planning care for a preschooler who will be having a surgical procedure in the morning. The child has been crying despite his parents’ presence at his bedside. The nurse should add engaging the child in therapeutic play to the care plan to offer which of the following benefits? - Allow the child to manipulate toy medical equipment Nurse is providing teaching to the parent of a child who has ADHD and a new prescription of methylphenidate sustained-release tablets. Which of the following statements by the parent indicates an understanding of the teaching - I should give this medication to my child half an hour before breakfast Nurse is teaching an adolescent about various strategies for chronic pain management. Which of the following activities should the nurse use as an example of the non pharmacological strategy of thought stopping? - Repeat memorized facts about the painful events Nurse is preparing to assess a 2 year old toddler. Which of the following behaviors should the nurse expect during the examination? - The child prefers to sit on the parents’ lap during the examinationNurse is providing teaching to the parent of an infant who has heart failure and a new prescription for digoxin elixir. Which of the following pieces of information should the nurse include? - Withhold the medication if the infant’s heart rate is less than 110/min Nurse is caring for an infant who has pertussis. Which of the following actions should the nurse take? - Maintain a cardiorespiratory monitor Nurse is caring for a group of infants with congenital heart defects. For which of the following defects should the nurse expect to observe cyanosis? - Transposition of the great arteries Nurse is teaching the guardians of an infant who has mild gastroesophageal reflux (GER). Which of the following instructions about feeding therapies should the nurse recommend? - Thicken feedings with rice cereal Nurse is providing discharge teaching to the guardian of an infant following a hypospadias repair. Which of the following instructions should the nurse include? - apply antibacterial ointment to the infant’s penis once per day Nurse is caring for a 4 week old infant who is 2 weeks postoperative following surgical correction of biliary atresia. Which of the following findings is an indication that the surgery was successful? - Infant has a total bilirubin level of 0.3 mg/dL Nurse is assessing the gross motor skills of a 4 year old preschooler. The nurse should expect the preschooler to perform which of the following activities? - Hopping on 1 foot Adverse effect of opioids - Pruritus Nurse is caring for a 4 month old infant who has tetralogy of fallot and experiences a hypercyanotic spell. Which of the following actions should the nurse take? - Place the infant in knee-chest position Nurse is caring for a child who has a possible intussusception. The parents of the child asks the nurse how the diagnosis is determined. Which of the following responses should the nurse make? - An abdominal ultrasound will confirm the pocket in the intestineNurse is assessing a school aged child after a ventriculoperitoneal (VP) shunt replacement. Which of the following findings indicates a complication of this procedure? - Abdominal distension Nurse is caring for a 6 year old child who is experiencing encopresis. Which of the following actions should the nurse take? - Determine if there are any recent stressors in the child’s environment Nurse is caring for a 16 year old client who reports dysmenorrhea and asks about alternative therapies for treatment. Which of the following statements should the nurse make? - Herbal medication can be effective but should be monitored by your provider Nurse is caring for a preschooler who was brought to an outpatient clinic with a 2 day history of a vesicular, honey colored crusty region around the nose and mouth. If the provider determines the lesions to be impetigo contagiosa, what should the nurse anticipate teaching the child’s parent about the illness? (SATA) - Apply a topical antibacterial ointment to the lesion - Wash the child’s bed linens daily with hot water - Wash hands before and after contact with the affected area Nurse is caring for a toddler who is postoperative following a cleft palate repair. Which of the following actions should the nurse take? - Restrain the toddler’s arms at the elbows Nurse is planning preoperative teaching for a preschooler who is scheduled for a tonsillectomy. Which of the following interventions should the nurse plan to include? - Let child bring his favorite toy to the hospital Nurse is providing teaching for a parent about pinworm testing at which of the following times should the nurse advise the parent to perform the tape test? - immediately after the child wakes up in the morning Manifestation of DKA: - Deep, rapid respirations Nurse is preparing to administer an enema to a 10 month old infant. Which of the following actions should the nurse plan to take? - Hold the infant’s buttocks together after administering the fluid Nurse is caring for a 4 year old child who has pneumonia. The child’s mother left 2 hours ago, and he is currently experiencing the separation anxiety stage of despair. Which of the following findings should the nurse expect? - Inactivity and thumb suckingNurse is caring for a child who has an epistaxis. Which of the following actions should the nurse perform? - Apply continuous pressure to the child’s nose for at least 10 min Nurse is providing discharge teaching for the parent of a newborn who is prescribed a Pavlik harness for developmental dysplasia of the hip. Which of the following responses indicates an understanding of the teaching? - I should lightly massage my baby underneath the straps once a day Nurse in the emergency department is admitting a child who has full-thickness burns over 45% of his body. Which of the following actions should the nurse take first? - Administer iv fluid replacement Nurse is assessing a 6 month old infant during a well-child visit. Which of the following motor activities should the nurse expect the infant to have achieved? - Turning from back to stomach Nurse is providing teaching about immunization schedules to the parents of a newborn who is 1 week old. Which of the following pieces of information should the nurse include in the teaching? - Initial vaccines should be administered between birth and 2 weeks of age Nurse is caring for an adolescent who has end-stage renal disease and is scheduled for peritoneal dialysis. Which of the following actions should the nurse take? - Obtain the adolescent’s weight prior to the procedure Nurse is providing teaching to the parent of a child who has cystic fibrosis and a prolapsed rectum. The nurse should identify that which of the following is a cause of this complication? - Bulky stools Nurse is providing teaching about home care to the guardian of an adolescent who has hemophilia. Which of the following pieces of information should the nurse provide - Encourage adolescents to participate in non-contact sports Nurse is caring for an 8 year old child who has sickle cell anemia. Which of the following actions should the nurse take? - Give the child flavored popsicles Nurse is providing teaching to the parent of a 1 month old infant who has gastroesophageal reflux. Which of the following statements by the parent indicates an understaindig of the teaching? - I will add rice cereal to my baby’;s feedingsNurse is providing anticipatory guidance about the accidental ingestion of a toxic substance to the parents of a toddler. The nurse should instruct the parents to take which of the following actions first if the child ingests a hazardous substance? - Call the poison control center Which of the following findings should the parent expect in an 18 month old toddler? - vocabulary of 10 or more words Nurse is assessing an infant who has acute gastroenteritis. Which of the following findings should the nurse identify as the priority? - Cap refill 5 seconds Nurse is preparing to administer routine immunizations to a 6 year old child. In addition to DTaP vaccine; theMMR vaccine, and the varicella vaccine, which of the following immunizations should the nurse plan to administer? - Inactivated poliovirus vaccine (IPV) Nurse is caring for a child who is receiving treatment for diabetic ketoacidosis (DKA) and has a current blood glucose level of 250 mg/dL. Which of the following actions should the nurse take? - Administer 5% dextrose in 0.9% sodium chloride by continuous IV infusion Nurse is assessing a child who has bilateral pheochromocytoma. Which of the following findings should the nurse expect? - Hypertension Type 1 diabetes mellitus. Which insulin injection site to use during basketball competitions? - Hip Nurse is reviewing laboratory findings of an adolescent who has acute renal failure. Which of the following findings should the nurse expect? - Metabolic acidosis Nurse is caring for an 18-year old adolescent who is up to date on immunizations and is planning to attend college. The nurse should recommend which of the following immuniczations prior to moving into a campus dormitory? - Meningococcal polysaccharide Nurse is caring for a 4 month old child who is hospitalized. Which of the following toys should the nurse provide for the child? - Plastic mirror Nurse is providing teaching to the guardian of a child who has kawasaki disease. Which of the following statements by the guardian indicates an understanding of the teaching? (SATA) - My child will likely be irritable for the next few weeks- I will ensure my child does not receive any live vaccines for at least 18 months - I will keep a record of my child’s temperature until she has no fever for several days Child who has acute glomerulonephritis. Which of the follwiing findings should the nurse expect? - Periorbital edema Nurse is providing teaching to the parent of a toddler who is undergoing insertion of tympanostomy tubes. Which of the following statements should the nurse include? - The tubes should stay in place until they fall out on their own Child who has acute glomerulonephritis. Which of the following actions should the nurse take: - Check the child’s blood pressure every 4 hr Which of the following suggestions should the nurse offer to the parent sot promote the child’s food intake? - let your child with others when possible Nurse is providing education to the parent of a toddler who is abut to receive an MMR immunization. Which of the following statements by the paren indicates an understanding of the teaching? - I will help my child to blow bubbles during the injection Nurse is caring for an unaccompanied infant following a motor vehicle crash. During the assessment, the nurse notes that the infant’s anterior fontanel is almost closed. She has 6 teeth, is able to sit unsupported, and can drink from a cup. The child cries whenever anyone new to her enters the room, saya a few words, and is asking for mama and dada. The nurse should make which of the following age assessments for this child? - 12 months old Nurse is teaching the parent of a preschool aged child about the treatment for pinworms. Which of the following statements by the parent indicates an understanding of the teaching? - I will give my child a dose of albendazole today and again in 2 weeks Nurse is caring for an infant who has gastroenteritis and is dehydrated. Wich of the following characteristics places the infant at a higher risk of electrolyte imbalances compared to an adult client? - Longer intestinal tract Nurse is teaching about clinical manifestations of tracheomalacia to the parent of an infant who had tracheoesophafeal fistula repair as a newborn. Which of the following findings shoudl the nurse include in the teaching? - Barking coughNurs eis caring for an adolescent following a lumbar puncturel which of the following actions should the nurse take? - Place the adolescent in a supine position [Show More]

Last updated: 2 years ago

Preview 1 out of 38 pages