NURSING 106 NURSING SPECIALTY

The nurse is caring for a 3-year-old child who is 2 hours postop from a cardiac catheterization via the right femoral artery. Which assessment finding is an indication of arterial obstruction? A. Blood pressure trend ...

The nurse is caring for a 3-year-old child who is 2 hours postop from a cardiac catheterization via the right femoral artery. Which assessment finding is an indication of arterial obstruction? A. Blood pressure trend is downward, and pulse is rapid and irregular. B. Right foot is cool to the touch and appears pale and blanched. C. Pulse distal to the femoral artery is weaker on the left foot than right foot. D. The pressure dressing at right femoral area is moist and oozing blood. 2. Following a motor vehicle collision, a 3-year-old girl has a spica cast applied. Which toy is best for the nurse for this 3-year-old child? A. Duck the squeaks. B. Fashion doll and clothes. C. Set of cloth and hand puppets. D. Handheld video game. 3. An infant with tetralogy of Fallot becomes acutely cyanotic and hyperpneic. Which action should the nurse implement first? A. Administer morphine sulphate. B. Start IV fluids. C. Place the infant in a knee-chest position. 4. A child admitted with diabetic ketoacidosis is demonstrating Kussmaul respirations. The nurse determines that the increased respiratory rate is a compensatory mechanism for which acid base alteration? A. Metabolic alkalosis. B. Respiratory acidosis. C. Respiratory alkalosis. D. Metabolic acidosis 5. A 7-year-old is admitted to the hospital with persistent vomiting, and a nasogastric tube attached to low intermittent suction is applied. Which finding is most important for the nurse to report to the healthcare provider? A. Gastric output of 100 mL in the last 8 hours. B. Shift intake of 640 mL IV fluids plus 30 mL PO ice chips. C. Serum potassium of 3.0 mg/dL. D. Serum pH of 7.45. 6. The nurse is evaluating diet teaching for a client who has non tropical sprue (celiac disease). Choosing which food indicates that the teaching has been effective? A. Creamed corn. B. Pancakes. C. Rye crackers. D. Cooked oatmeal. 7. During a well-baby check, the nurse hides a block under the baby’s blanket, and the baby looks for the block. Which normal growth and development milestone is the baby developing? A. Separation anxiety. B. Associate play. C. Object prehension. D. Object permanence. 8. The nurse is measuring the frontal occipital circumference (FOC) of a 3-months old infant, and notes that the FOC has increased 5 inches since birth and the child’s head appears large in relation to body size. Which action is most important for the nurse to take next? A. Measure the infant’s head-to-toe length. B. Palpate the anterior fontanel for tension and bulging. C. Observe the infant for sunken eyes. D. Plot the measurement on the infant’s growth chart. 9. The nurse is preparing a 10-year-old with a lacerated forehead for suturing. Both parents and 12-year-old sibling are at the child’s bedside. Which instruction best supports family? A. While waiting for the healthcare provider, only one visitor may stay with the child. B. All of you should leave while the healthcare provider sutures the child’s forehead. C. It is best if the sibling goes to the waiting room until the suturing is completed. D. Please decide who will stay when the healthcare provider begins suturing. 10. The nurse is planning for a 5-month-old with gastroesophageal reflux disease whose weight has decreased by 3 ounces since the last clinic visit one month ago. To increase caloric intake and decrease vomiting, what instructions should the nurse provide this mother? A. Give small amounts of baby food with each feeding. B. Thicken formula with cereal for each feeding. C. Dilute the child’s formula with equal parts of water. D. Offer 10% dextrose in water between most feedings. 11. While teaching a parenting class to new parents the nurse describes the needs of infants and toddlers regarding discipline and limit setting. What is the most important reason for implementing such parenting behaviors? A. Children need help in developing social skills. B. This age child fears loss of self-control. C. They provide the child with a sense of security. D. Children must learn to deal with authority. 12. The parents of a newborn infant with hypospadias are concerned about when the surgical correction should occur. What information should the nurse provide? A. Repair should be done by one month to prevent bladder infection. B. To form a proper urethra repair, it should be done after sexual maturity. C. Repairs typically should be done before the child is potty trained. D. Delaying the repair until school age reduces castration fears. 13. Which drink choice on a hot day indicates to the nurse that a teenager with sickle cell anemia understands dietary consideration related to the disease? A. Milkshake. B. Iced tea. C. Diet cola. D. Lemonade. 14. The nurse is assessing an infant with diarrhea and lethargy. Which finding should the nurse identify that is consistent with early dehydration? A. Tachycardia. B. Bradycardia. C. Dry mucous membrane. D. Increased skin turgor. 15. While auscultating the lung sounds of a 5-year-old Chinese boy who recently completed antibiotic therapy for pneumonia, the nurse notices symmetrical, round, bruise-like blemishes on his chest. What action is best for the nurse to take? A. Identify the antibiotic used to treat the pneumonia. B. Inquire about the use of alternative methods of treatment. C. Ask the parents if the child has been in a recent accident. D. Report suspected child abuse to the authorities. 16. A child witch acute lymphocytic leukemia (ALL) who is receiving chemotherapy via a subclavian IV infusion, has an oral temperature of 103 degrees. In assessing the IV site, the nurse determines that there are no signs of infection at the site. Which intervention is the most important for the nurse to implement? A. Obtain specimen for blood cultures. B. Assess the CBC. C. Monitor the oral temperature every hour. D. Administer acetaminophen as prescribed. 17. A child who weighs 25 kg is receiving IV ampicillin 300 mg/kg/24 hours in equally divided doses every 4 hours. How many mg should the nurse administer to the child for each dose. Ans. 300 x 25 = 7500/4 = 1875 18. The nurse is caring for an infant scheduled for reduction of intussusceptions. The day before the scheduled procedure the infant passes a soft-formed brown stool. Which intervention should the nurse implement? A. Instruct the parents that the infant needs to be NPO. B. Notify the healthcare provider of the passage of brown stool. C. Obtain a stool specimen for laboratory analysis. D. Ask the parents about recent changes in the infant’s diet. 19. The mother of a 4-month-old asks the nurse for advice in preventing diaper rash. What suggestion should the nurse provide? A. At diaper change generously powder the baby’s diaper area witch talcum powder to promote dryness. B. Wash the diaper area every 2 hours with soap and water to help prevent skin breakdown. C. Use a barrier cream, such as zinc oxide, which does not have to be completely removed with each diaper change. D. Place a cloth diaper inside the disposable diaper for overnight periods when increased wearing time is likely. 20. Which statement by a school aged client going to summer camp indicates the best understanding of the mode of transmission of Lyme disease? A. I’ll cover my mouth with a wet cloth if there’s too much dust blowing. B. Cuts and scrapes need to be washed out and covered right away. C. I’m not going to swim where the water is standing still or feels too hot. D. I have to wear long sleeves and pants when we’re hiking around the pond. 21. The nurse is evaluating the effects of thyroid therapy used to treat a 5-month-old with hypothyroidism. Which behavior indicates that the treatment has been effective? A. Laughs readily, turns from back to side. B. Has strong moro and tonic neck reflexes. C. Keeps fists clenched, opens hands when grasping an object. D. Can lift head, but not chest when lying on abdomen. 22. The HR for a 3-year-old with a congenital heart defect has steadily decreased over the last few hours, now it’s 76 bpm, the previous reading 4 hours ago was 110 bpm. Which additional finding should be reported immediately to a healthcare provider? A. Oxygen saturation 94%. B. RR of 25 breaths/min. C. Urine output 20 mL/hr. D. BP 70/40. 23. A 2-year-old is admitted to the hospital with possible encephalitis, and a lumbar puncture is scheduled. Which information should the nurse provide this child concerning the procedure? A. Describe the side-lying, knees to chest position that must be assumed during the procedure. B. Tell the child to expect loud clicking noises during the procedure that may be slightly annoying. C. Reassure the child that there will be no restrictions on activity after the procedure is completed. D. Explain that fluids cannot be taken for 8 hours before the procedure and for every 4 hours after the procedure. 24. The parents of a 3-year-old boy who has Duchenne muscular dystrophy (DMD) asks, “how can our son have this disease? We are wondering if we should have any more children.” What information should the nurse provide these parents? A. This is an inherited x-linked recessive disorder, which primarily affects male children in the family. B. The male infant had a viral infection that went unnoticed and untreated, so muscle damage was incurred. C. The XXXX muscle groups of males can be impacted by a lack of the protein dystrophy in the mother. D. Birth trauma with a breech vaginal birth causes damage to the spinal cord, thus weakening the muscles. 25. The nurse finds a 6-month-old infant unresponsive and calls for help. After opening the airway and finding the XXXX the infant is still not breathing. Which action should the nurse take? A. Palpate femoral pulse and check for regularlity. B. Deliver cycles of 30 chest compressions and 2 breaths. C. Give two breaths that makes the chest rise. D. Feel the carotid pulse and check for adequate breathing. 26. A 3-year-old with HIV infections is staying with a foster family who is caring for 3 other foster children in their home. When one of the children acquires pertussis, the foster mother calls the clinic and asks the nurse what she should do. Which action should the nurse take first? A. Remove the child who has HIV from the foster home. B. Report the exposure of the child with HIV to the health department. C. Place the child who has HIV in reverse isolation. D. Review the immunization documentation of the child who has HIV. 27. A 16-year-old female student with a history of asthma controlled with both an oral antihistamine and an albuterol (Proventil) metered-dose inhaler (MDI) comes to the school nurse. The student complains that she cannot sleep at night, feels shaky and her heart feels like it is “beating a mile per minute.” Which information is most important for the nurse to obtain?