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The nurse is giving pre-op instructions to a 14 yr old female scheduled for surgery to correct a spinal
curvature. Which stmt best demonstrates that leaning has taken place?
"I understand that I will be in a body cast and I will show you how you taught me to turn"
To take the v/s of a 4 month old, which ordered will give the most accurate results?
RR - HR - rectal temp
During routine screening at a school clinic, an otoscope exam reveals a tympanic mb that is pearly gray,
slightly bulging, and not movable. What action should the nurse take next?
Ask the child if they have had a cold, runny nose, or any ear pain lately
Which restraint should be used for a toddler after a cleft palate repair?
Elbow
What pre-op nsg intervention should be included in the POC for an infant w/ pyloric stenosis?
Observe for projectile vomiting
(remember that projectile vomiting leads to metabolic alkalosis)
A 6 month old returns from surgery w/ elbow restraints in place. What nsg care should be included
when caring for any restrained child?
Remove the restraints one at a time and provide ROM exercises
(Removing them 1 at a time is safer than all at once)
A 2 yr old w/ Down syndrome is brought to the clinic for his regular physical exam. The nurse knows
which problem is requently associated w/ Downs?
Congenital heart disease
()CHD is the most common associated defect w/ Downs. - also, remember Professor Moore said that
heart and ear problems go hand in hand
When assessing a child w/ asthma, the nurse should expect intercostal retractions during
Inspriation
, When planning the care for a child who has had a cleft lip repair, the nurse know that crying should be
minimized because it
Stresses the suture line
A full-term infant is admitted to the newborn nursery. After careful assessment, the nurse suspects that
the infant may have an esophageal atresia. Which sx's is this newborn likely to have exhibited?
Choking , coughing, and cyanosis
(this answer includes the 3 "C"s of esophageal atresia caused by the overflow of secretions to the
trachea)
Which behavior would the nurse expect a 2 yr old to exhibit?
Display possessiveness of toys
(they are egocentric and unable to share w/ others)
the other of a preschool-aged child asks the nurse if it is all right to administer Pepto Bismol to her son
when he has a tummy ache. After reminding her to check the label of all OTC meds for the presence of
ASA, which instruction should the nurse include when replying to the mom's question?
Do not give if they have chicken pox, the flue, or any other viral illness
(ASA can cause Reye's syndrome)
the nurse observes a 4 yr old boy in a daycare. Which behavior should the nurse consider normal for this
child?
Demonstrates aggressiveness by boasting when telling a story
A burned child is brought to the ER. In estimating the % of body burned, the nurse uses a modified "Rule
of Nines." Which part of the body is calculated as a larger % of total body surface than an adult?
Head and neck
(a child's head and neck are proportionately larger to their body than an adult's)
The nurse receives a lab report stating a child w/ asthma has a theophylline level of 15mcg/dL. What
action will the nurse take?
Pass the info on in the report
(therapeutic level is 10-20)
A 12 month old is admitted w/ a respiratory infection and possible pneumonia. He is placed in a mist
tent w/ O2. Which nsg intervention has the greatest priority?
Have a bulb syringe readily available to remove secretions