ATI RN Nursing Care of Children Online Practice 2019 B Latest Update 2023/2024

ATI RN Nursing Care of Children Online A nurse is planning care for a newly admitted schole-age child who has generalized seizure disorder. Which of the following interventions should the nurse plan to include? - CORRECT ANSWER Ensure the oxygen source is functioning in the childs room: The nurse should recognize that maintaining the child's airway is important during a seizure. The nurse should ensure that the oxygen source is functioning because the child might require supplemental oxygen following a seizure. A nurse is providing dietary teaching to the guardian of a school-age child who has cystic fibrosis. Which of the following statements should the nurse make? - CORRECT ANSWER "You should offer your child high-protein meals and snacks throughout the day." The nurse should instruct the guardian to provide a diet that is well-balanced and high in protein and calories. Children who have cystic fibrosis require a higher percentage of the recommended dietary allowances of all nutrients to meet their energy requirements. Children who have good nutritional intake have improved lung function and decreased risk of infection. A nurse is providing discharge teaching to the parents of a 6-month-old infant who is postoperative following hypospadias repair with a stent placement. Which of the following instructions should the nurse include in the teaching? - CORRECT ANSWER "Allow the stent to drain into your infants diaper." The nurse should instruct the parents to ensure that the stent drains directly into the infant's diaper to prevent kinking or twisting that can interfere with urine flow. A nurse is caring for a school-age child who has primary nephrotic syndrome and is taking prednisone. Following 1 week of treatment, which of the following manifestations indicates to the nurse that the medication is effective? - CORRECT ANSWER Decreased edema: A child who has nephrotic syndrome can experience edema due to the increased glomerular permeability, which increases protein loss. Prednisone decreases glomerular permeability, which causes fluid to shift from the extracellular spaces, resulting in decreased edema. A nurse is receiving change-of-shift report for four children. Which of the following children should the nurse assess first? - CORRECT ANSWER A toddler who has a concussion and an episode of forceful vomiting.: When using the urgent vs. nonurgent approach to client care, the nurse should assess this child first. An episode of forceful vomiting is an indication of increased intracranial pressure in a toddler who has a concussion. A nurse is providing discharge teaching to the guardians of a toddler who had lower leg cast applied 24 hr ago. The nurse should instruct the guardians to report which of the following finding to the provider? - CORRECT ANSWER Restricted ability to move the toes.: The nurse should inform the guardians that a restricted ability of the toddler to move their toes is an indication of neurovascular compromise and requires immediate notification of the provider. Permanent muscle and tissue damage can occur in just a few hours. A nurse in an emergency department is auscultating the lungs of an adolescent who is experiencing dyspnea. The nurse should identify the sound as which of the following? - CORRECT ANSWER Wheezes: The nurse should identify the sound during auscultation as wheezes, which are high-pitched, musical or whistling-like sounds heard primarily on expiration as air passes through and vibrates narrowed airways. A nurse is caring for a preschooler who has congestive heart failure. The nurse observes wide QRS complexes and peaked T waves on the cardiac monitor. Which of the following prescriptions should the nurse clarify with the provider? - CORRECT ANSWER Potassium Chloride: The nurse should identify that a child who has congestive heart failure can develop electrolyte imbalances, such as hyperkalemia or hypokalemia. The nurse should identify that the child is exhibiting manifestations of hyperkalemia and contact the provider about the administration of potassium chloride, which can increase the severity of hyperkalemia. A nurse is planning an educational program for school-age children and their parents about bicycle safety. Which of the following information should the nurse plan to include? - CORRECT ANSWER The child should be able to stand on the balls of their feet when sitting on the bike.: To decrease the risk for injury, parents should ensure that the bike is the correct size for the child. When seated on the bike, the child should be able to stand with the ball of each foot touching the ground and should be able to stand with each foot flat on the ground when straddling the bike's center bar. A nurse is monitoring the oxygen saturation level of an infant using pulse oximetry. The nurse should secure the sensor to which of the following areas on the infant? - CORRECT ANSWER Great Toe. The nurse should secure the sensor to the great toe of the infant and then place a snug-fitting sock on the foot to hold the sensor in place. The nurse should also check the skin under the sensor site frequently for temperature, color, and the presence of a pulse. A nurse is an emergency department is caring for a school-age child who has epiglottitis. Which of the following actions should the nurse take? - CORRECT ANSWER Monitor the childs oxygen saturation: The nurse should monitor the child's oxygen saturation level because the child is experiencing acute respiratory distress and it is necessary to determine if the child is responding to treatment. A nurse in an emergency department is caring for a school-age child who has sustained a minor superficial burn from fireworks on their forearm. Which of the following actions should the nurse take? - CORRECT ANSWER Apply an antimicrobial ointment to the affected area.: The nurse should apply an antimicrobial ointment to the burned area to prevent infection. A nurse in a providers office is caring for a school-age child who has varicella. The parents asks the nurse when their child will no longer be contagious. Which of the following responses should the nurse make? - CORRECT ANSWER "When your childs lesions are crusted, usually 6 days after they appear.": The nurse should inform the parent that the child is contagious 1 day prior to lesion eruption and until the vesicles have crusted over, which usually takes about 6 days. A nurse is providing discharge teaching to the parent of a school-age child who has moderate persistant asthma. Which of the following instructions should the nurse include? - CORRECT ANSWER "Pulmonary function tests will be performed every 12 to 24 months to evaluate how your child is responding to therapy.": The nurse should inform the parent that their child will need pulmonary function tests every 12 to 24 months to evaluate the presence of lung disease and how the child is responding to the current treatment regimen. As children grow, sometimes their manifestations can improve or decline, and treatment needs to change accordingly. A nurse is admitting an infant who has intussusception. Which of the following findings should the nurse expect? (Select all that apply.) - CORRECT ANSWER -Vomiting -Lethargy Vomiting is correct. The nurse should expect an infant who has intussusception to exhibit vomiting due to the obstruction that occurs when a segment of the bowel telescopes within another segment of the bowel.Lethargy is correct. The nurse should expect an infant who has intussusception to exhibit lethargy due to episodes of severe pain during which the infant cries inconsolably, leading to exhaustion and decreased nutritional intake. A nurse is reviewing the laboratory results of a school-age child who is 1 week postoperative following an open fracture repair. Which of the following findings should the nurse identify as an indication of a potential complication? - CORRECT ANSWER Erythrocyte sedimentation rate 18 mm/hr: The nurse should identify that an erythrocyte sedimentation rate of 18 mm/hr is above the expected reference range of up to 10 mm/hr and is an indication of osteomyelitis. A nurse is providing discharge teaching to the parents of a 3-month old infant following a cheiloplasty. Which of the following instructions should the nurse include? - CORRECT ANSWER "Apply a thin layer of antibiotic ointment on the your babys suture line daily for the next 3 days.": The nurse should instruct the parents to apply a thin layer of antibiotic ointment on the infant's suture line daily for 3 days and then continue to apply petroleum jelly to the area for several weeks to promote healing. A nurse is discussion organ donation with the parents of a school-age child who has sustained brain death due to a bicycle crash. Which of the following actions should the nurse take first? - CORRECT ANSWER Explore the parents feelings and wishes regarding organ donation.: The first action the nurse should take when using the nursing process is assessment. The nurse should first explore the parents' feelings and wishes regarding organ donation to assist in determining if organ donation is the right choice for the family. A nurse is caring for a 1-month-old infant who is breastfeeding and requires a heel stick. Which of the following actions should the nurse take to minimize the infants pain? - CORRECT ANSWER Allow the mother to breastfeed while the sample is being obtained.: The nurse should allow the mother to breastfeed the infant prior to or during the procedure. Evidence-based practice indicates breastfeeding or non-nutritive sucking with a pacifier can provide nonpharmacological pain management in infants. A nurse is assessing an adolescent who received a sodium polystyrene sulfonate enema. Which of the following findings indicates effectiveness of the medication? - CORRECT ANSWER Serum potassium level 4.1 mEq/L, The nurse should monitor the adolescent's serum potassium level following the administration of sodium polystyrene sulfonate. This medication is used to treat hyperkalemia by exchanging sodium ions for potassium ions in the intestine. Therefore, a potassium level within the expected reference range of 3.4 to 4.7 mEq/L indicates the effectiveness of the medication. A charge nurse is preparing to make a room assignment for a newly admitted school-age child. Which of the following considerations is the nurses priority? - CORRECT ANSWER Disease process: The transmission of infectious diseases is the greatest risk to this child and other children on the unit. Therefore, the child's disease process is the nurse's priority consideration A nurse is assessing the pain level of a 3-year-old toddler. Which of the following pain assessment scales should the nurse use? - CORRECT ANSWER FACES: The nurse should use the FACES pain rating scale for pediatric clients who are 3 years old and older. This scale allows the toddler to point to the face that depicts their current level of pain. The nurse can then determine the need for pain management. A nurse is preparing to administer ibuprofen 5 mg/kg every 6 hr PRN for a temperatures above 38.0 C (100.5 F) to an infant who weighs 17.6 lb. Available is ibuprofen oral suspension 100mg/5mL. How many mL should the nurse administer to the infant per dose? - CORRECT ANSWER 2 mL A nurse is assessing a 6-month-old infant during a well-child visit. Which of the following findings should the nurse report to the provider? - CORRECT ANSWER Presence of strabismus: Strabismus, or crossing of the eyes, typically disappears at 3 to 4 months of age. If not corrected early, this can lead to blindness. Therefore, the nurse should report this finding to the provider. A school nurse is caring for a child following tonic-clonic seizure. Which of the following actions should the nurse take first? - CORRECT ANSWER Check the childs respiratory rate.: When using the airway, breathing, and circulation approach to client care, the nurse should determine the priority action is to assess the child's respiratory rate. If the child is not breathing, the nurse should administer rescue breaths. A nurse is planning developmental activities for a newly admitted 10-year-old child who has neutropenia. Which of the following actions should the nurse plan to take? - CORRECT ANSWER Provide the child with a book about adventure.: The nurse should provide a school-age child with a book about adventure as a developmental activity because children are expanding their knowledge and imagination during this age. Through reading, school-age children can feel powerful and skillful as they imagine themselves in the stories they read. A nurse in a health department is caring for an emancipated adolescent who has an STI and is unaccompanied by a guardian. Which of the following actions should the nurse take? - CORRECT ANSWER Have the adolescent sign a consent form for treatment.: The nurse should identify that an emancipated minor can sign the consent form for treatment of an STI or any other form of medical treatment requiring consent. A nurse is assessing an 8-year-old child who has early indications of shock. After establishing an airway and stabilizing the childs respirations, which of the following actions should the nurse take next? - CORRECT ANSWER Initiate IV access.: After establishing an airway and stabilizing the child's respirations, the next action the nurse should take when using the airway, breathing, and circulation approach to client care is to establish IV access to maintain the child's circulatory volume. A nurse is performing hearing screenings for children at a community health fair. Which of the following children should the nurse refer to a provider for a more extensive hearing evaluation? - CORRECT ANSWER An 8-month-old who is not yet making babbling sounds.: The nurse should refer an infant who is not making babbling sounds by the age of 7 months to a provider for a more extensive evaluation of hearing A nurse is providing discharge teaching to the guardian of a school-age child who has undergone a tonsillectomy. Which of the following statements by the guardian indicates an understanding the teaching? - CORRECT ANSWER "I will notify the doctor if I notice that my child is swallowing frequently." A community health nurse is assessing an 18-month-old toddler in a community day care. Which of the following findings should the nurse identify as a potential indication of physical neglect? - CORRECT ANSWER Poor personal hygiene: A toddler who has poor personal hygiene can be a potential indication of physical neglect. Because toddlers are still dependent on their parents or guardians for help with hygiene needs, poor personal hygiene can indicate a lack of supervision. A nurse assessing a school-age child who has an infratentorial brain tumor. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure? - CORRECT ANSWER Difficulty concentrating: The nurse should identify that irritability, inability to follow commands, and difficulty concentrating are manifestations of increased intracranial pressure due to decreased blood flow within the brain and pressure on the brainstem. A nurse is providing teaching to an adolescent about how to manage tinea pedis. Which of the following statements by the adolescent indicates an understanding of the teaching? - CORRECT ANSWER "I should wear sandals as much as possible.": Sandals allow air to circulate around the feet, decreasing perspiration and eliminating the medium for bacteria and fungus to grow. The nurse should inform the adolescent that wearing sandals, open-toed, or well-ventilated shoes will promote healing of the fungal infection. A nurse is caring for a school-age child who has diabetes mellitus and was admitted with a diagnosis of diabetic ketoacidosis. When performing the respiratory assessment, which of the following findings should the nurse expect? - CORRECT ANSWER Deep respirations of 32/min: The nurse should expect Kussmaul respirations in a child who has diabetic ketoacidosis. These deep and rapid respirations are the body's attempt to eliminate excess carbon dioxide and achieve a state of homeostasis. A nurse is planning n educational program to teach parents about protecting their children from sunburns. Which of the following instructions should the nurse plan to include? - CORRECT ANSWER "Choose a waterproof sunscreen with a minimum SPF of 15.": The nurse should instruct parents to apply a waterproof sunscreen with a minimum SPF of 15 for children. The parents should apply the sunscreen prior to sun exposure to reduce the risk of sunburn. A nurse is providing teaching to the parents of a preschooler who has heart failure and a new prescription for digoxin twice daily. Which of the following instructions should the nurse include in the teaching? - CORRECT ANSWER "Brush the childs teeth after giving the medication.": The nurse should teach the parent to closely monitor the child's number of wet diapers. Monitoring the number of wet diapers per day is an effective way for the parent to monitor adequate output and hydration status. A nurse is providing teaching to the family of a school-age child who has juvenile idiopathic arthritis. Which if the following instructions should the nurse include in the teaching? - CORRECT ANSWER "Encourage the child to perform independent self-care.": The nurse should teach the family the importance of encouraging the child to perform independent self-care. This will minimize the child's pain while maximizing mobility. Encouraging and praising the child's efforts for independence will also increase their self-esteem. A nurse is creating a plan of care for a child who has varicella. Which of the following interventions should the nurse include? - CORRECT ANSWER Initiate airborne precautions for the child.: The nurse should initiate airborne precautions for a child who has varicella because it is spread through droplets in the air. The incubation period for varicella is 2 to 3 weeks, and the child is contagious even before lesions appear. A nurse is assessing a school-age child who has an acute spinal cord injury following a sports injury 1 week ago. Identify the area the nurse should tap to elicit the bicep reflect. - CORRECT ANSWER Correct answer is A A school nurse is providing an in-service for faculty about improving education for students who have ADHD. Which of the following statements by a faculty member indicates an understanding of the teaching? - CORRECT ANSWER "I will teach challenging academic subjects to students who have ADHD in the morning." Faculty should plan to teach challenging academic subjects in the morning when students who have ADHD are most able to focus and their medication is most likely to be effective A nurse is caring for a school-age child who has peripheral edema. The nurse should identify that which of the following assessments should be performed to confirm peripheral edema? - CORRECT ANSWER Palpate the dorsum of the childs feet: The nurse should palpate the dorsum of the feet by pressing the fingertip against a bony prominence for 5 seconds to assess for peripheral edema. A nurse is caring for an infant who is receiving IV fluids for the treatment of Tetralogy of Fallot and begins to have hypercryanotic spell. Which of the following actions should the nurse take? - CORRECT ANSWER Place the infant in a knee-chest position: The nurse should place the infant in a knee-chest position during a hypercyanotic spell to decrease the return of desaturated venous blood from the legs and to direct more blood into the pulmonary artery by increasing systemic vascular resistance. A nurse is reviewing the dietary choices of an adolescent who has iron deficiency anemia. The nurse should identify that which of the following menu items has the highest amount of nonheme iron? - CORRECT ANSWER ½ cup raisins: The nurse should encourage the adolescent to eat raisins because they contain the highest amount of nonheme iron. A nurse in an emergency department is assessing a 3-month-old infant who has rotavirus and is experiencing acute vomiting and diarrhea. Which of the following manifestations should the nurse identify as an indication that the infant has moderate to severe dehydration? - CORRECT ANSWER Sunken anterior fontanel: The nurse should recognize that a sunken anterior fontanel is an indication of moderate to severe dehydration due to the acute loss of fluid. A nurse is planning care for a school-age child who has tunneled central venous access device. Which of the following interventions should the nurse include in the plan? - CORRECT ANSWER Use a semipermeable transparent dressing to cover the site: The nurse should cover the site with a semipermeable transparent dressing to reduce the risk of infection. A nurse is teaching a group of parents about infectious mononucleosis. Which of the following statements by parent indicates an understanding the teaching? - CORRECT ANSWER "Mononucleosis is caused by an infection with the Epstein-Barr virus.": The nurse should identify that mononucleosis is a mildly contagious illness that occurs sporadically or in groups, and is primarily caused by the EpsteinBarr virus. A nurse is caring for a newly admitted school-age child who has hypopituitarism. Which of the following medications should the nurse expect the provider to prescribe? - CORRECT ANSWER Recombinant growth hormone: Recombinant growth hormone injections are used to treat hypopituitarism, which inhibits cell growth and results in growth failure. The nurse should expect the provider to prescribe this treatment. A nurse is creating a plan of care for a preschooler who has Wilms' tumor and is scheduled for surgery. Which of the following interventions should the nurse include? - CORRECT ANSWER Avoid palpating the abdomen when bathing the child before surgery.: The nurse should avoid palpating the abdomen when bathing the child before surgery because movement of the tumor can cause cancer cells to disseminate to other sites, adjacent and distant to the tumor site. A nurse is providing discharge teaching to the parent of an 18-month-old toddler who has dehydration due to acute diarrhea. Which of the following statements by the parent indicates an understanding of the teaching? - CORRECT ANSWER "I will monitor my childs number of wet diapers.": The nurse should teach the parent to closely monitor the child's number of wet diapers. Monitoring the number of wet diapers per day is an effective way for the parent to monitor adequate output and hydration status. A nurse is teaching the guardian of a 6-month-old infant about teething. Which of the following statements should the nurse make? - CORRECT ANSWER "Your baby might pull at their ears when they are teething." A nurse is creating a plan of care for a newly admitted adolescent who has bacterial meningitis. How long should the nurse plan to maintain the adolescent in droplet precautions? - CORRECT ANSWER For 24 hr following initiation of antimicrobial therapy: The nurse should plan to maintain the adolescent on droplet precautions for at least 24 hr following initiation of antimicrobial therapy. This practice will ensure that the adolescent is no longer contagious, which protects family members and the personnel caring for the client. Prophylactic antibiotics might be prescribed to individuals who were in close contact with the adolescent. A nurse is providing anticipatory guidance to the parent of a toddler. Which of the following expected behavior characteristics of toddlers should the nurse include? - CORRECT ANSWER Expressed likes and dislikes: The nurse should include that expressing likes and dislikes is an expected behavior of toddlers. This is the time in life when a toddler is developing autonomy and self-concept. They will try to assert themselves and frequently refuse to comply. The parent should allow the child to have some control, but also set limits for them so they learn from their behavior and learn to control their actions. A nurse is admitting a 4-month-old infant who has heart failure. Which of the following findings is the nurses priority? - CORRECT ANSWER Episodes of vomiting: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is three episodes of vomiting. This can indicate digoxin toxicity, which requires immediate intervention. Therefore, this is the nurse's priority finding. A nurse in an emergency department is assessing a toddler who has Kawasaki disease. Which of the following findings should the nurse expect? (Select all that apply.) - CORRECT ANSWER -Increased temperature -Xerophthalmia -Cervical lymphadenopathy Increased temperature is correct. Kawasaki disease is an acute illness associated with a fever that is unresponsive to antipyretics or antibiotics.Gingival hyperplasia is incorrect. Children who have Kawasaki disease develop a strawberry tongue, cracked lips, and edema of the oral mucosa and pharynx. A child who is receiving phenytoin therapy can develop gingival hyperplasia.Xerophthalmia is correct. Ophthalmic manifestations of Kawasaki disease include reddening of the conjunctiva and dryness of the eyes, or xerophthalmia.Bradycardia is incorrect. Kawasaki disease is an infection that affects the vascular system, including the heart. The nurse should expect the child to be tachycardic with a gallop rhythm. Long-term effects of Kawasaki disease include the development of coronary artery aneurysms or myocardial infarction.Cervical lymphadenopathy is correct. A child who has Kawasaki disease can develop enlarged cervical nodes on one side of the neck that are nontender and greater than 1.5 cm in size. A nurse is caring for a 10-year-old child following a head injury. Which of the following findings should the nurse identify as an indication that the child is developing diabetes insipidus? - CORRECT ANSWER Sodium 155 mEq/L: A child who has a head injury can develop diabetes insipidus as a result of pituitary hypofunction leading to a deficiency of antidiuretic hormone. Underexcretion of antidiuretic hormone leads to polyuria and polydipsia, and possibly dehydration. With the excessive loss of free water, sodium levels rise above the expected reference range of 136 to 145 mEq/L. A nurse is planning care to address nutritional needs for a preschooler who has cystic fibrosis. Which of the following interventions should the nurse include in the plan? - CORRECT ANSWER Increase fat content in the childs diet to 40% of total calories.: A child who has cystic fibrosis is unable to properly digest fats due to fibrosis of the pancreas and limited secretion of pancreatic enzymes. The nurse should increase the child's fat intake to 35% to 40% of total caloric intake. A nurse is caring for a toddler who has acute otitis media and a temperature of 40 C (104 F). After administering acetaminophen, which of the following actions should the nurse plan to take to reduce the toddler's temperature? - CORRECT ANSWER Dress the toddler in minimal clothing.: The nurse should recognize that dressing the toddler in minimal clothing will expose the skin to air and maximize heat evaporation from the skin, thus reducing the toddler's temperature. A nurse is teaching a school-age child and their parent about postoperative care following cardiac catheterization. Which of the following instructions should the nurse include? - CORRECT ANSWER "Wait 3 days before taking a tub bath.": The child should keep the site clean and dry for at least 3 days to reduce the risk of infection. Tub baths should be avoided for 3 days to avoid immersion of the incision in water. A nurse is assessing an infant who has pneumonia. Which of the following findings is the priority for the nurse to report to the provider? - CORRECT ANSWER Nasal flaring: When using the airway, breathing, and circulation approach to client care, the nurse should determine that the priority finding to report to the provider is nasal flaring. Nasal flaring indicates the infant is experiencing acute respiratory distress. 52. A nurse is teaching the parents of a toddler who has cognitive impairment about toilet training. Which of the following instructions should the nurse include in the teaching? - CORRECT ANSWER "Award your child with a sticker when they sit on the potty chair.": A child who has a cognitive impairment learns through shaping behaviors. The parents should reward the child for sitting on the potty chair as a reinforcement of the desired behavior of continence. As the child repeats this action, the parents can gradually decrease this reward and then give rewards for the next step in the task, such as voiding while sitting on the potty chair. EDKH - CORRECT ANSWER Epstein Didn't Kill Himself If a child has an allergy to neomycin with a anapylactic reaction what vaccine should you withhold? or an allergy to eggs or gelatin - CORRECT ANSWER measles, mumps, rubella (MMR) what is an indication of bacterial meningitis? - CORRECT ANSWER increased protein concentration, increased WBC, decreased glucose level, increased cerebrospinal fluid pressure normal HCT for a child - CORRECT ANSWER 32 - 44% what can a child experience with a low HCT? - CORRECT ANSWER tachycardia, lightheadedness, fatigue, dyspnea, pallor normal wbc for child - CORRECT ANSWER 5,000 - 10,000 mm3 normal platelet for child - CORRECT ANSWER 150,000-400,000 normal Hgb for child - CORRECT ANSWER 9.5-14 g/dL normal prealbumin for child - CORRECT ANSWER 15-33 mg/dL pavlik harness - CORRECT ANSWER used for hip dysplasia in infants Remove only to take baths, place diapers under the harness straps, do not use products becuase can cause skin irritation, and do not adjust straps peritonitis - CORRECT ANSWER inflammation of the peritoneum (membrane lining the abdominal cavity and surrounding the organs within it) abdominal distension, chills, irritability, restlessness scoliosis - CORRECT ANSWER should expect to see a unilateral rib hump with hip flexion peristalis - CORRECT ANSWER involuntary waves of muscle involves contractions of the smooth muscles that push the food toward the stomach what should you expect with a child following a perforated appendix repair? - CORRECT ANSWER absence of peristalsis what to do following a lumbar puncture? - CORRECT ANSWER apply topical analgesic 1 hr before, place client in prone or flat position for up to 12 hours after, encourage to drink extra fluids nursing interventions for a child with an epidural hematoma? - CORRECT ANSWER neuro checks q15mins, avoid suctioning nares, implement seizure activity, position infant midline slightly elevated nursing interventions for a child scheudled for a wound debridement? - CORRECT ANSWER apply topical ointment following hydrotherapy, apply gauze after therapy, administer an analgesic beforehand, and AVOID prophylactic antibiotic therapy who can sign consent? - CORRECT ANSWER over 18 y/o, parent of a minor, or if under 18 and married can sign themselves nursing interventions for a child in a tonic clonic seizure. - CORRECT ANSWER turn to side, no food or drink, nothing by mouth (meds) epinephrine - CORRECT ANSWER treats anaphylaxis Prednisone - CORRECT ANSWER treats severe inflammation Anti-inflammatory Diphenhydramine - CORRECT ANSWER Benadryl, decreases allergic reaction Albuterol - CORRECT ANSWER Bronchodilator, improves childs breathing ventricular septal defect - CORRECT ANSWER nurse should expect to hear a loud harsh murmur due to the left to right shunting of blood coarction of the aorta (CoA) - CORRECT ANSWER narrowing of the aorta, should expect to have high blood pressure and weak femoral pulses indication of early septic shock - CORRECT ANSWER increased heart rate, normal BP, fever and chills, normal urinary output how to test for a sickle turbidity test - CORRECT ANSWER perform a finger stick, if test is positive hemoglobin electrophoresis is required to distinguish b/w children who have the genetic trait and children who have the disease McBurney's point - CORRECT ANSWER A point on the right side of the abdomen, about two-thirds of the distance between the umbilicus and the anterior bony prominence of the hip normal urine output for an adolescent - CORRECT ANSWER 33 to 62.5 mL/hr Osteomyelitis Nursing Interventions - CORRECT ANSWER avoided bearing weight, antibiotics for several weeks pertussis - CORRECT ANSWER whooping cough; highly contagious bacterial infection of the pharynx, larynx, and trachea caused by Bordetella pertussis Bacterial conjunctivitis - CORRECT ANSWER pinkeye; very contagious, purulent eye drainage Acute Streptococcal Pharyngitis - CORRECT ANSWER inflamed throat with exudate, strep throat Rubeola (measles) - CORRECT ANSWER Highly contagious infection caused by a member of the paramyxovirus family, koplik spots on buccal mucosa Diaper dermatitis treatment - CORRECT ANSWER Keeping the area dry and applying Zinc Oxide and petrolatum. burns treatment - CORRECT ANSWER no prophylactic antibiotic therapy, cleanse area with mild soap and water, apply antimicrobial ointment, for major burn management maintain decompression of stomach via NG tube Syndrome of Inappropriate Antidiuretic Hormone (SIADH) - CORRECT ANSWER caused by the overproduction of the antidiuretic hormone ADH, may have mental confusion and neurological manifestations when severe, over hydration needle size for 4 y/o childs immunizations - CORRECT ANSWER 22 - 25 gauge needle to minimize pain Meningitis manifestations - CORRECT ANSWER headaches, nuchal rigidity, positive kernig's sign nuchal rigidity - CORRECT ANSWER stiffness in cervical neck area opisthotonos position - CORRECT ANSWER backward bending, assumed with nervous system complications Dehydration manifestations - CORRECT ANSWER skin breakdown, hypotension, hyperpyrexia, tachypnea childs vital signs - CORRECT ANSWER BP: S:86-118, D:44-74 HR: 80-120 RR:20-25/min high serum lead level in children - CORRECT ANSWER > 45 mcg/dL provide chelating agents, but in some cases > 10 mcg/dL, provide high calcium diet to help decrease lead absorption, yearly screenings bucks traction nursing interventions - CORRECT ANSWER maintain supine position, assess peripheral pulses every 4 hours, head flat child milestones - CORRECT ANSWER 4 y/o: cuts outline shape using scrissors 5 y/o: draws stick figure with seven body parts 6 y/o: spread butter with utensils & identifies right from left hand appendicitis - CORRECT ANSWER inflammation of the vermiform appendix, treat with morphine celiac disease - CORRECT ANSWER NO barley, wheat, oat, rye. substitute with soy, rice & corn anaphylactic reaction - CORRECT ANSWER severe reaction occurring immediately after exposure to a drug; characterized by respiratory distress and vascular collapse Epinephrine medication - CORRECT ANSWER given to help breathing during a anaphylactic reaction Hemolytic transfusion reaction - CORRECT ANSWER Back pain is an adverse reaction, hypotension, tachycardia Febrile blood transfusion reaction - CORRECT ANSWER Chills, fever, headache, flushing, tachycardia, anxiety. Allergic blood transfusion reactions - CORRECT ANSWER Mild- Itching, hives, flushing- Administer benadryl Anaphylactic- wheezing, dyspnea, chest tightness, cyanosis, hypotension -maintain airway, admin. 02, IV fluids, antihistamines, corticosteroids, and vasopressors (pyramidal) Spastic Cerebral Palsy - CORRECT ANSWER A type of cerebral palsy in which the person has very tight muscles occurring in one or more muscle groups, resulting in stiff, uncoordinated movements (ankle clonus, exaggerated strech reflex, contractures) (Dyskinetic) nonspastic Cerebral Palsy - CORRECT ANSWER Cerebral palsy that involves continuous involuntary movements associated with hyperbilirubinemia and damage to basal nuclei ganglion; manifestations include drooling and uncontrollable movements of the face and extremeties Ataxic Cerebral Palsy - CORRECT ANSWER a type of cerebral palsy that is characterized by poor balance and equilibrium in addition to uncoordinated voluntary movement. But can still walk with a slow gait where should 02 be placed for child - CORRECT ANSWER great toe, check for pulse frequently and cover with sock signs of digoxin toxicity - CORRECT ANSWER vomiting Hypopituitarism - CORRECT ANSWER state of deficient pituitary gland activity, stunts growth, use recombinant growth hormone medication diabetes insipidus - CORRECT ANSWER antidiuretic hormone is not secreted adequately, or the kidney is resistant to its effect. normal blood glucose, extremely thirsty & dehydrated. Expect higher sodium due to excessive loss of free water. sodium polystyrene sulfonate (Kayexalate) - CORRECT ANSWER Antidote for hyperkalemia Tetralogy of Fallot - CORRECT ANSWER congenital malformation involving four distinct heart defects, place infant in knee chest position to bring blood back to heart and 100% 02 via face mask. peripheral edema - CORRECT ANSWER Swelling in the limbs, particularly the feet and ankles, due to an accumulation of interstitial fluid. palpate the dorsum of the child's feet for 5 seconds cystic fibrosis nutrition - CORRECT ANSWER administer pancreatic enzyme within 30 minutes of eating, may need to increase dosage by provider until steatorrhea resolves, encourage fluids, increase fat content to 35-40% of toal caloric intake nursing interventions for tunnneled central venous access device - CORRECT ANSWER semipermeable transparent dressing, use a noncoding angles or striaght needle when accessing, flush wiht heparin solution dialy when not in use, avoid use of scissors Kawasaki disease - CORRECT ANSWER (inflammation of blood vessles, hence the strawberry tongue) causes coronary artery aneurysms. sudden and recent deprivation of food (protein) Marsamus - CORRECT ANSWER severe lack of food over a long period of time, resulting from inadewuate energy & protein tinea pedis - CORRECT ANSWER fungal infection of the foot; athlete's foot, wear sandals as much as possible to allow air to circulate intussusception - CORRECT ANSWER telescoping of a segment of the intestine within itself, lethragy and vomiting are expected due to episodes of severe pain and obstruction Kussmaul respirations - CORRECT ANSWER Deep, rapid breathing; usually the result of an accumulation of certain acids when insulin is not available in the body. In keto acidosis. Potassium Chloride - CORRECT ANSWER do not give in peaked T WAVE when should a baby begin to make babble noises - CORRECT ANSWER 7 months varicella - CORRECT ANSWER chickenpox, airborne, keep room cool, avoid aspirin Digoxin - CORRECT ANSWER cardiac glycoside, brush teeth after to avoid teeth decay from sweetened liquid, vomiting is a sign of toxicity prevent sids - CORRECT ANSWER pacifier at bedtime juvenille arthritis - CORRECT ANSWER encourage self care celiac disease - CORRECT ANSWER can't digest gluten -malabsorption -steatorrhea -diarrhea tinea pedis - CORRECT ANSWER wear sandals (fungal infection between toes) car seat - CORRECT ANSWER secure by using lower anchors & tethers instead of seat belt head injury = diabetes insipidus - CORRECT ANSWER high sodium level due to dehydration pituitary hypofunction leading to deficiency of anti-diuretic hormone eye drops - CORRECT ANSWER give eye drops, wait 3 mins to give ointment sickle-turbidity test - CORRECT ANSWER perform a finger stick peripheral edema - CORRECT ANSWER palpate dorsum of foot burn - CORRECT ANSWER wash with soap & water to prevent infection hearing evaluation - CORRECT ANSWER no babbling by 7 months gluten free - CORRECT ANSWER no -oats -barley -rye -wheat rice pudding is gluten free digoxin - CORRECT ANSWER wash teeth after to prevent tooth decay oral nystatin - CORRECT ANSWER shake medication prior to use epidural hematoma - CORRECT ANSWER initiate seizure precautions cheilopasty (lip reduction) - CORRECT ANSWER apply anbtibiotic ointment to sutures sodium polystyrene enema - CORRECT ANSWER monitor potassium treat hyperkalemia spastic (pyridimal) cerebral palsy - CORRECT ANSWER -ankle clonus -exaggerated stretch reflex -contractures suggestive physical abuse - CORRECT ANSWER symmetric burns of lower extremeties inappropriate anti-diuretic hormone secretion - CORRECT ANSWER mental confusion - decrease in urine -hyponatremia -hyposmolaity (overhydration) MMR vaccine contraindicaiton - CORRECT ANSWER neomycin allergy (no allergies to eggs/gelatin) sunburns - CORRECT ANSWER sunscreen with 15 SPF 4 year old - CORRECT ANSWER cuts shapes with scizzors kawasaki disease - CORRECT ANSWER -increased temp -xerophtalmia -cervical lymphadenopathy scoliosis - CORRECT ANSWER -unilateral rib hump bacterial meningitis - CORRECT ANSWER increased protein concentration in spinal fluid erythema infectiosum (fifth disease) - CORRECT ANSWER facial rash epiglottis - CORRECT ANSWER prepare for nasotracheal intubation ventricular septal defect - CORRECT ANSWER loud, harsh murmur left to right shunting of blood = hypertrophy of heart muscle cardiac cath post-op - CORRECT ANSWER wait 3 days before tub bath tonic-clonic seizure - CORRECT ANSWER place child in lateral position diaper dermatitis - CORRECT ANSWER apply zinc oxide tobramycin (aminoglyceride) - CORRECT ANSWER assess for hearing loss diabetic ketoacidosis - CORRECT ANSWER deep respiration rate high blow off excess carbon dioxide hypopituitarism - CORRECT ANSWER give RECOMBINANT GROWTH HORMONE (inhibits cell growth, results in growth failure) intussuception - CORRECT ANSWER -vomiting -lethargy burn - CORRECT ANSWER apply antimicrobial ointment acute rheumatic fever - CORRECT ANSWER maintain bedrest, to prevent cardiac damage failure to thrive - CORRECT ANSWER -observe parents reaction feeding child -maintain strict I/O 12 month nutrition - CORRECT ANSWER skim milk not reccommended until age 2 lacks fatty acids for growth toddler venupuncture - CORRECT ANSWER supine most common allergy in children - CORRECT ANSWER cow's milk immunizations 2 month old - CORRECT ANSWER haemophilus influenzae type b (HIB) inactivated polio virus (IPV) water heater - CORRECT ANSWER 49 C = 120 F do not exceed adult tetanus booster - CORRECT ANSWER age 7 or older reccommended every 10 years after 18 peek-a-boo - CORRECT ANSWER object permanence object still exists when out of sight 6 month old - CORRECT ANSWER babinski present (until 1 year old) increased risk for hospitilization stress - CORRECT ANSWER males temporary loss of vision - CORRECT ANSWER explain sounds the child is hearing ingested bleach - CORRECT ANSWER injury by corrosive liquid is worse than solid birth weight - CORRECT ANSWER 12 months = triple 30 months = quadroopled relaxation strategy - CORRECT ANSWER rock baby intusseception - CORRECT ANSWER invasion of one intestine into another creating a pocket - x ray -ultrasound -ct scan management hypoglycemia - CORRECT ANSWER 10-15 grams simple carbohydrates (8 ounce milk) sickle cell anemia, vaso-occlusive crisis - CORRECT ANSWER maintain bed rest minimize energy & O2 needs surgical repair cleft palate - CORRECT ANSWER suction gently with bulb syrine PRN maintain airway scoliosis brace - CORRECT ANSWER wear 23 hours a day only remove for shower or PT tracheomalacia - CORRECT ANSWER weakened trachea = collapse -barking cough* -stridor -wheezing cyanosis -apnea surgical myelomeningocele complication - CORRECT ANSWER pathway for cerebral spinal fluid is altered risk for hydrocephalus measels (rubeola) - CORRECT ANSWER koplick spots* -fever -malaise -conjuctivitis -cold ss 2 year old diet - CORRECT ANSWER 1,000 calories asthma - CORRECT ANSWER report sudden stop of wheezing child has HIV - CORRECT ANSWER -pneumococcal -influenza reccommended pinworms - CORRECT ANSWER give ALBENDAZOLE today & again in 2 weeks eradicate parasite & prevent infection ASO titer - CORRECT ANSWER recent strep infection test epiglottis - CORRECT ANSWER ***drooling*** pyloromyotomy surgery - CORRECT ANSWER 4-6 hours after, feed small, bottle feedings of electrolyte solution ear drops - CORRECT ANSWER massage anterior area of infants ear ventricular septal defect - CORRECT ANSWER murmur at the left sternal border gastroesphogeal reflux - CORRECT ANSWER add rice to baby's feedings thick = reduce vomiting 5 year old immunizations - CORRECT ANSWER diptheria, tetanus, & pertussis (dTap) boosters between 4-6, blood titers drop due to decreasing antibodies nephrotic syndrome - CORRECT ANSWER high cholesterol bc of increased plasma lipids school aged child surgery - CORRECT ANSWER schedule pre-operative visit to facility vesicular rash - CORRECT ANSWER varicella acute glomerulonephritis - CORRECT ANSWER monitor bp every 4 hours for hypertension sickle cell anemia - CORRECT ANSWER give popsicles hydration prevents sickeling anaphylaxis - CORRECT ANSWER -nausea -uticaria -stridor autism - CORRECT ANSWER bring stuffed animal to hospital tetralogy of fallet - CORRECT ANSWER cyanosis increase RBC in attempt to supply O2 to body otitis media - CORRECT ANSWER amoxicillin (antibiotic) intussception - CORRECT ANSWER barium enema may not need surgery transposition of great arteries - CORRECT ANSWER severe cyanosis rheumatic fever pain - CORRECT ANSWER aspirin for joint pain leukemia - CORRECT ANSWER low RBC A nurse is assessing a school-age child immediately postoperative following a perforated appendix repair. Which of the following findings should the nurse expect? - CORRECT ANSWER absence of peristalsis A nurse is assessing the vital signs of a 10-year-old child following a burn injury. Which of the following clinical manifestations indicate early septic shock? - CORRECT ANSWER temp of 39.1 A school nurse is preparing to administer atomoxetine 1.2 mg/kg/day PO to a school-age child who weighs 75 lb. Available is atomoxetine 40 mg/capsule. How many capsules should the nurse administer per day? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero - CORRECT ANSWER 1 A nurse is caring for a school-age child who is receiving chemotherapy and is severely immunocompromised. Which of the following actions should the nurse take? Screen the child's visitors for indications of infection - CORRECT ANSWER potential for an overwhelming infection A nurse is reviewing the laboratory report of a 7-year-old child who is receiving chemotherapy. Which of the following laboratory values should the nurse report to the provider - CORRECT ANSWER The nurse should recognize that a hemoglobin level of 8.5 g/dL is below the expected reference range for a 7-yearold child and should be reported to the provider. Nurse caring for 15 y/o who's married and scheduled for surgical procedure. Client asks " Who should sign my surgical consent?" Which responses should the nurse make? - CORRECT ANSWER "You can sign the consent form because you are married." Nurse teaches parents of school age child with new Dx of osteomyelitis of tibia. Which statements by parent indicates an understanding of teaching? - CORRECT ANSWER My child will receive antibiotics for several weeks. Nurse is teaching school age child with new dx of T1DM. Which statements by child indicates an understanding of teaching? - CORRECT ANSWER I will give myself a shot of regular insulin 30 minutes before I eat breakfast.": Nurse cares for school age child receiving cefazolin via intermittent IV bolus. Child suddenly develops diffuse flushing skin and angiodema. After discontinuing med infusion, which meds should the nurse admin first? - CORRECT ANSWER epinephrine Nurse auscultates lungs of adolescent with asthma. Nurse should ID sound as what? - CORRECT ANSWER tachypnea A nurse at an urgent care clinic is assessing an adolescent client who has an upper resp tract infection. Which of the following findings should the nurse recognize as a manifestation of pertussis? - CORRECT ANSWER dry, hacking cough Nurse caring for toddler with spastic (pyramidal) cerebral palsy. Which findings should the nurse expect? (SATA) - CORRECT ANSWER Ankle clonus, Exaggerated stretch reflexes, Contractures Nurse in ED is performing physical assessment on 2 week old male newborn. Which findings is priority for nurse to report to HCP? - CORRECT ANSWER Substernal retractions: Nurse cares for adolescent who received kidney transplant. Which findings should the nurse ID as indication adolescent is rejecting the kidney? - CORRECT ANSWER Serum creatinine 3.0 mg/dL Nurse assessing toddler with gastroenteritis and exhibits manifestations of dehydration. Which findings is the nurse's priority? - CORRECT ANSWER tachypnea Nurse creating POC for infant with epidural hematoma from head injury. Which interventions should the nurse include in plan? - CORRECT ANSWER Implement seizure precautions for the infant Nurse teaching parents of infant with Pavlik harness for tx of hip dysplasia. Nurse should ID which statements by parent indicating understanding of teaching? - CORRECT ANSWER I will place my infant's diapers under the harness straps. Nurse caring for toddler experiencing acute diarrhea and moderate dehydration. Which nutritional items should the nurse offer to toddler? - CORRECT ANSWER oral rehydration solution Nurse admits a school age child with pertussis. Which actions should the nurse take? - CORRECT ANSWER Initiate droplet precautions for the child Charge nurse in ED is preparing an inservice for a group of newly licensed nurses about manifestations for child maltreatment. Which manifestations should the charge nurse include as potential indications of physical abuse? - CORRECT ANSWER Symmetric burns of the lower extremities: Nurse caring for school age child in Buck's traction following a leg fracture 24 hrs ago. Which actions should the nurse take? - CORRECT ANSWER Assess peripheral pulses once every 4 hr: Nurse is planning care for toddler with serum lead 4 mcg/dL. Which actions should the nurse plan to take? - CORRECT ANSWER Schedule the toddler for a yearly rescreening: School nurse assesses adolescent with multiple burns in various stages of healing. Which behaviors should the nurse ID as possible indication of physical abuse? - CORRECT ANSWER Denies discomfort during assessment of injuries Nurse gives discharge teaching to parent of child 1 week postop following cleft palate repair. Which members of interprofessional team should the nurse initiate a referral? - CORRECT ANSWER speech therapist nurse teaching the parent of an infant about ways to prevent SIDS. Which instructions should the nurse include - CORRECT ANSWER Give the infant a pacifier at bedtime Nurse caring for school age child experienced a tonic-clonic seizure. Which actions should the nurse take during the immediate postictal period? - CORRECT ANSWER Place the child in a side-lying position Hospice nurse is caring for preschooler with terminal illness. One parent of patient tells the nurse that they cannot cope anymore and are thinking about moving out of the house. Which statement should the nurse make? - CORRECT ANSWER Let's talk about some of the ways you have handled previous stressors in your life.": Nurse in ED is caring for school age child experiencing anaphylacitic reaction. Which priority action should be done by the nurse? - CORRECT ANSWER Administer epinephrine IM to the child Nurse in ED is caring for toddler with partial thickness burns on right arm. Which actions should the nurse take? - CORRECT ANSWER Cleanse the affected area with mild soap and water: Nurse assesses school age child with peritonitis. Which findings should the nurse expect? - CORRECT ANSWER abdominal distension Nurse assesses 3 y/o toddler at a well-child visit. Which manifestations should the nurse report to HCP? - CORRECT ANSWER Respiratory rate 45/min Nurse cares for preschooler whose father is going home for a few hours while another relative stays with child. Which statements should the nurse make to explain to child when their father will return? - CORRECT ANSWER Your daddy will be back after you eat. A nurse is reviewing the lab report of an infant who is receiving tx for severe dehydration. The nurse should identify that which of the following lab values indicates effectiveness of the current tx? - CORRECT ANSWER sodium 140 Nurse teaches parent of preschooler about ways to prevent acute asthma attacks. Which statements by parent indicates understanding of teaching? - CORRECT ANSWER I should keep my child indoors when I mow the yard.": Nurse is providing teaching to parent of infant with diaper dermatitis. Nurse should instruct parent to apply what to the affected areas? - CORRECT ANSWER Zinc Oxide Nurse is planning care for school age child in oliguric phase of AKI and has sodium level 129 mEq/L. Which interventions should the nurse include in plan? - CORRECT ANSWER Initiate seizure precautions for child Nurse reviews lab report of school age child experiencing fatigue. Which findings should the nurse recognize as an indication of anemia? - CORRECT ANSWER Hematocrit 28% Nurse assesses 4 y/o child at well-child visit. Which developmental milestone should the nurse expect to observe? - CORRECT ANSWER Cuts an outlined shape using scissors Nurse caring for school age child receiving blood transfusion. Which manifestation should alert the nurse to possible hemolytic transfusion reaction? - CORRECT ANSWER Flank pain Nurse is providing teaching about play activities for social development to parents of preschooler. Which play activities should nurse recommend for child? - CORRECT ANSWER Playing dress-up School nurse assesses an adolescent with scoliosis. Which findings should the nurse expect? - CORRECT ANSWER A unilateral rib hump: Nurse is creating POC for school age child with heart disease and has developed heart failure. Which interventions should the nurse include in plan? - CORRECT ANSWER Provide small, frequent meals for the child Nurse is caring for infant with resp syncytial virus (RSV). Which actions should the nurse implement for infection control? - CORRECT ANSWER Have a designated stethoscope in the infant's room Nurse assesses infant with ventricular septal defect. Which findings should the nurse expect? - CORRECT ANSWER Loud, harsh murmur: Nurse teaches the guardian of 6 month/old infant about care seat use. Which statements by guardian indicates understanding of teaching? - CORRECT ANSWER "I should secure the car seat using lower anchors and tethers instead of the seat belt." Nurse is preparing to collect sample from toddler for sickle-turbidity test. Which actions should the nurse plan to take? - CORRECT ANSWER Perform a finger stick Nurse assesses school age child with meningitis. Which findings is priority for the nurse to report to HCP? - CORRECT ANSWER Petechiae on the lower extremities Nurse is preparing an adolescent for lumbar puncture. Which actions should the nurse take? - CORRECT ANSWER Apply topical analgesic cream to the site 1 hr prior to the procedure Nurse provides dietary teaching to parent of school age child with celiac disease. Nurse should recommend parent offer which foods to child? - CORRECT ANSWER white rice Nurse teaches parent of school age child with new prescription for oral nystatin for tx of oral candidiasis. Which instructions should the nurse include? - CORRECT ANSWER "Shake the medication prior to administration." Nurse in provider's office prepares to admin immunizations to toddler during well-child visit. Which actions should the nurse plan to take?Exhibit:Tuberculin skin test (TST), Measles, mumps, and rubella (MMR) vaccine, Inactivated influenza vaccine, Diphtheria, tetanus, and pertussis (DTaP) vaccine, RR 24/min, HR 115/min, Temp 36.9° C (98.4° F), Age 15 months, Height 71.1 cm (28 in), Allergies Neomycin (anaphylactic reaction), Caregiver reports rhinitis with clear nasal drainage for 2 days, Occasional nonproductive cough for 2 days, History of asthma - CORRECT ANSWER Withhold the measles, mumps, and rubella (MMR) vaccine Nurse in ED is caring for school age child with appendicitis and rates abd. pain 7/10. Which actions should the nurse take? - CORRECT ANSWER Give morphine 0.05 mg/kg IV: Nurse prepares to admin an immunization to 4 yo child. Which actions should the nurse plan to take? - CORRECT ANSWER Administer the immunization using a 24-gauge needle Nurse reviews lumbar puncture results of school-age child with suspected bacterial meningitis. Which findings should the nurse ID as an indication of bacterial meningitis? - CORRECT ANSWER Increased protein concentration Nurse cares for preschooler scheduled for hydrotherapy tx for wound debridement following burn injury. Which actions should the nurse take prior to procedure? - CORRECT ANSWER Administer an analgesic to the child Nurse interviews parent of 18 month old toddler during well-child visit. Nurse should ID which findings that indicates a need to assess toddler for hearing loss? - CORRECT ANSWER The toddler received tobramycin during a hospitalization 2 weeks ago Nurse caring for 15 y/o client following head injury. Which findings should the nurse ID as indication that child's developing SIADH? - CORRECT ANSWER Mental confusion Nurse cares for preschooler receiving IV fluids via peripheral IV catheter. When preparing to discontinue IV fluids and catheter, which actions should the nurse plan to take? - CORRECT ANSWER First, the nurse should turn off the IV pump. Next, the nurse should occlude the IV tubing, and then remove the tape securing the catheter. Last, the nurse should apply pressure over the catheter insertion site. Nurse receives change of shift report for 4 children. Which children should nurse see first? - CORRECT ANSWER A school-age child who has sickle cell anemia and reports decreased vision in the left eye Nurse caring for adolescent with severe abd. pain due to appendicitis. Which location should the nurse ID as McBurney's point? - CORRECT ANSWER This area of the right lower quadrant located about twothirds of the way between the umbilicus and the client's anterosuperior iliac spine is the area where a client who has appendicitis is most likely to report pain and tenderness. A nurse is assessing the pain level of a 3 year old toddler. Which of the following assessment scales should the nurse use? a. FACES b. Numeric c. CRIES d. Visual analog - CORRECT ANSWER A A nurse is planning an educational program to teach parents about protecting their children from sunburns. Which of the following instructions should the nurse plan to include? a. "allow your child to play outside during the hours between 10:00am and 2:00pm." b. "choose a waterproof sunscreen with a minimum SPF of 15." c. "dress you child in loose weave polyester fabric prior to sun exposure." d. "reapply sunscreen every 4 hours." - CORRECT ANSWER B A nurse is performing hearing screenings for children at a community health fair. Which of the following children should the nurse refer to a provider for a more extensive hearing evaluation? a. an 18 month old toddler who has unintelligible speech b. a 3 month old infant who has exaggerated startle response c. a 4 year old preschooler who prefers playing with others rather than alone d. an 8 month old infant who is not yet making babbling sounds - CORRECT ANSWER D A nurse in an emergency department is assessing a 3 month old infant who has rotavirus and is experiencing acute vomiting and diarrhea. Which of the following manifestations should the nurse identify as an indication that the infant has moderate to severe dehydration? a. HR 124 b. increased tear production c. sunken anterior fontanel d. capillary refill 2 seconds - CORRECT ANSWER C A nurse is providing teaching to the family of a school-age child who has juvenile idiopathic arthrisis. Which of the following instructions should the nurse include in the teaching? a. "limit movement of the child's large joints" b. "encourage the child to perform independent self-care." c. "provide the child with a soft mattress for sleeping." d. "schedule a 2 hour daily nap for the child in the afternoon." - CORRECT ANSWER B A nurse is planning care for a school age child who has a tunneled central venous access device. Which of the following interventions should the nurse include in the plan? a. use sterile scissors to remove the dressing from the site b. irrigate each lumen weekly with 10 ml of 0.9% sodium chloride solution when not in use c. access the site suing a noncoring angle needle d. use a semipermeable transparent depressing to cover the site - CORRECT ANSWER D A nurse is providing anticipatory guidance to the parent of a toddler. Which of the following expected behavior characteristics of toddlers should the nurse include? a. controls impulsive feelings b. understands right from wrong c. easily separates from parents for long periods of time d. expresses likes and dislikes - CORRECT ANSWER D A nurse is providing discharge teaching to the parent of a school age child who has moderate persistent asthma. Which of the following instructions should the nurse include? a. "you should give your child their salmeterol inhaler every 4 hours when they are having an acute episode of wheezing." b. "you should monitor your child's weight weekly while they are receiving inhaled corticosteroids therapy." c. "pulmonary function tests will be performed every 12-24 months to evaluate how your child is responding to therapy." d. "when using the peak expiratory flow meter, record your child's average of three readings." - CORRECT ANSWER C A nurse is assessing an adolescent who received a sodium polystyrene sulfonate enema. Which of the following findings indicates effectiveness of the medication? a. reports an absence of nausea and vomiting b. reports experiencing an onset of loose stools within 15 minutes of administration c. serum potassium level 4.1 mEq/L d. blood pressure 86/52 mm Hg - CORRECT ANSWER C A nurse is assessing an infant who has pneumonia. Which of the following findings is the priority for the nurse to report the provider? a. nasal flaring b. WBC count 11,300/mm^3 c. diarrhea d. abdominal distension - CORRECT ANSWER A A nurse is providing discharge teaching to the guardian of a school age child who has undergone a tonsillectomy. Which of the following statements by the guardian indicates an understanding the teaching? a. "my child can resume usual activities since this year just an outpatient surgery." b. "my child will be able to drink the chocolate milkshake I promised to get for them tonight." c. "I will notify the doctor if I notice that my child is swallowing frequently." d. "I will have my child gargle with warm salt water to relieve their sore throat." - CORRECT ANSWER C A nurse is discussing organ donation with the parents of a school age child who has sustained brain death due to a bicycle crash. Which of the following actions should the nurse take first? a. inform the parents that written consent is required prior to organ donation b. provide written information to the parents about organ donation c. ask the provider to explain misconceptions of organ donation to the parents. d. explore the parents feelings and wishes regarding