The nurse is caring for a 3 year old child who is 2 hours postop from a cardiac catheritization via
the right femoral artery. Which assessment finding is an indication of arterial obstruction? -
ANSRight foot is cool to the touch and appears pale and blanched
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? - ANSSet of cloth and hand puppets
An infant with tetralogy of fallot becomes acutely cyanotic and hyperpneic. Which action should
the nurse implement first? - ANSPlace the infant in a knee-chest position
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? - ANSMetabolic Acidoses
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? - ANSSerum potassium of 3.0 mg/dL
The nurse is evaluating diet teaching for a client who has nontropical sprue (celiac disease).
Choosing which food indicates that the teaching has been effective? - ANSCreamed corn
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? -
ANSObject Permanence
The nurse is measuring he frontal occipital circumference (FOC) of a 3 month 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? - ANSPalpate
the anterior fontanel for tension and bulging
The nurse is preparing a 10 year old with a lacerated forehead for suturing. Both parents and 12
years old sibling are at the child's bedside. Which instruction best supports family? - ANSPlease
decide who will stay when the healthcare provider begins suturing
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? - ANSThicken
formula with cereal for each feeding
, 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? - ANSThey provide the child with a sense of security
The parents of a newborn infant with hypospadia are concerned about when the surgical
correction should occur. What information should the nurse provide? - ANSRepairs typically
should be done before the child is potty trained
Which drink choice on a hot day indicates to the nurse that a teenager with sickle cell anemia
understands dietary considerations related to the disease? - ANSLemonade
The nurse is assessing an infant with diarrhea and lethargy. Which finding should the nurse
identify that is consistent with early dehydration? - ANSTachycardia
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? - ANSInquire about the use of alternative
methods of treatment
A child with 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? - ANSObtain specimen for blood cultures
A child who weighs 25 kg is receiving IV ampicillin 300mg/kg/24 hours in equally divided doses
every 4 hours. How many mg should the nurse administer to the child for each dose? -
ANS1875mg
The nurse is caring for an infant scheduled for reduction of intussusceptions. The day before the
scheduled procedures the infant passes a soft-formed brown stool. Which intervention should
the nurse implement? - ANSNotify the healthcare provider of the passage of brown stool
The mother of a 4 month old asks the nurse to advice in preventing diaper rash. What
suggestion should the nurse provide? - ANSUse a barrier cream, such as zinc oxide, which
does not have to be completely removed with each diaper change
Which statement by a school aged client going o summer camp indicates the best
understanding of the mode of transmission of Lyme disease? - ANSI have to wear long sleeves
and pants when we're hiking around the pond
The nurse is evaluating the effects of thyroid therapy used to treat a 5 month old with
hypothyroidism. Which behavior indicates hat the treatment has been effective? - ANSLaughs
readily, turns from back to side