Hesi Peds, Capstone Nursing Care of Children, RN Nursing Care of Children Online Practice 2019 B

1. A nurse is providing education to a parent whose child has had a colostomy. Which of the following is an appropriate method to determine understanding of the teaching? - Observe the parents while they perform the procedure. 2. A nurse is educating the parent of a 9-month-old infant who has recently been diagnosed with cerebral palsy. Which of the following statements by the parent should indicate to the nurse that teaching has been effective? - "I am hopeful that the early schooling will increase my child's ability for selfcare." 3. A nurse is caring for a child who is in Buck's traction. Which of the following should the nurse recognize as an appropriate intervention to prevent complications? - Provide small meals with high fiber. 4. A nurse is providing diabetic teaching to a 12-year-old child who appears apprehensive during the teaching. Which of the following actions should the nurse recognize as appropriate in this situation? - Teach the child to do her own fingerstick 5. A nurse on the pediatric unit is caring for four clients who all have assessments ordered in the morning. Which of the following values should the nurse report to a client's primary care provider immediately? - Sickle cell anemia and a urine specific gravity of 1.030 6. A nurse is caring for a 3-year-old child who is scheduled for a nephrectomy. When preparing preoperatively, which of the following actions should the nurse recognize as appropriate? - Explain the procedure to the child in simple sentences just before administering the preoperative sedation 7. A nurse is caring for a child who is receiving chemotherapy with anorexia and nausea. Which of the following interventions should the nurse recognize as the most appropriate for the child experiencing these symptoms? - Allow the client to eat whatever the client wants, at any time. 8. The parent of a toddler asks the nurse why the toddler's abdomen protrudes. Which of the following statements would be an appropriate response by the nurse? - "The muscles of the abdomen are weak, and therefore, the abdomen protrudes." 9. A nurse is caring for a child who will be receiving PE tubes in the morning. The nurse is teaching the parents how to care for the tubes upon discharge. Which of the following statements should indicate to the nurse that the teaching was understood? - "I will keep water out of my child's ears 10. A nurse is caring for a child who has cellulitis and a rectal temperature of 102.2° F (39° C).The child has an order for acetaminophen (Tylenol) 280 mg by mouth. The label on the bottle reads 160 mg/5 mL. Which of the following is the correct dose the nurse should dispense to the child? - 8.8 mL 11. A nurse is caring for a child who is a vegetarian and has sustained superficial partial thickness burns on her legs. Which of the following diet choices would be appropriate for this child? - Peanut butter and jelly sandwich 12. A nurse is performing a yearly physical on an adolescent. The adolescent's parent asks about the adolescent's developmental needs. Which of the following statements by the parent should the nurse investigate further? - "He spends several hours a day on the internet 13. A nurse is caring for a child who has superficial partial-thickness burns over 50% of his body. In planning for the nutritional needs of the child, which of the following should the nurse recognize as an appropriate intervention? - Perform dressing changes at least 1 hr before or after meals 14. A nurse is caring for a child who has cystic fibrosis. Which of the following assessments should the nurse recognize as a priority to report to the primary care provider? - Inability to clear secretions 15. A nurse is preparing a 7-year-old child for a tonsillectomy. Which of the following nursing actions would be appropriate in this preparation? - Schedule the child for a preoperative visit to the hospital. 16. A nurse is caring for a child who has tetralogy of Fallot preoperatively. Which of following laboratory values should the nurse expect to find? - Hematocrit of 58% 17. A school nurse is assisting a child who has been stung by a bee. The child's hand is swelling and the nurse notes that the child has allergies to insect stings. Which of the following manifestations should the nurse recognize with anaphylaxis? (Select all that apply.) - Nausea is correct. A common gastrointestinal response to excessive histamine release is nausea. - Urticaria is correct. A common skin manifestation of excessive histamine release is hives (urticaria). - Stridor is correct. A serious, life-threatening response to excessive histamine release is airway narrowing, which presents as dyspnea and stridor. 18. A nurse is caring for a child who is undergoing a bone marrow aspiration. Which response by the child should indicate to the nurse that the teaching has been effective? - "I'll have to lie on my belly while it's done." 19. A nurse is preparing to administer an injection to a 2-month-old infant. Which of the following is an appropriate site for the nurse to give the injection? - Vastus lateralis 20. A nurse is caring for a toddler who has asthma. The parents are concerned about the toddler's reaction to the hospitalization. Which of the following nursing actions should the nurse perform to decrease the stress experienced by the toddler? - Encourage rooming-in 21. A school nurse is assessing a child who returned to school following a case of mononucleosis. The child has a note from his primary care provider excusing him from gym class. Which of the following should the nurse recognize as the most appropriate reason for this excuse? - Sustaining abdominal trauma 22. A nurse is caring for a 10-year-old child who is obese. Which of the following menu choices is the most appropriate for this child? - A glass of skim milk, baked fish sandwich on whole wheat roll with lettuce, and a medium apple 23. A nurse is assessing an adolescent who sustained a broken tibia while playing football. Following the application of a fiberglass cast, the client complains of pain and a tingling feeling in the limb. Which of the following is the most appropriate action for the nurse to take? - Assess for signs of circulatory impairment and swelling 24. A nurse is caring for a 7-year-old child diagnosed with glomerulonephritis. The child has decreased urinary output and a blood pressure of 160/78 mm Hg. The child is receiving hydralazine (Apresoline). Which of the following lunch choices should the nurse recognize as most appropriate? - Grilled chicken on a roll, pear slices, and 4 oz of apple juice 25. A charge nurse is assigning rooms for admissions. An 8-year-old child who is admitted with sickle cell anemia and is dehydrated. Which of the following is an appropriate room assignment for this child? - 10-year-old male; postoperative appendectomy 26. A nurse is caring for a child who has been brought to the emergency room after ingesting a bottle of acetaminophen (Tylenol). Which of the following medications should the nurse anticipate administering? - Acetylcysteine (Mucomyst) 27. A nurse receives the following laboratory values on a 2-month-old child who has cyanotic heart disease. The results are a hemoglobin of 17 g/dL and a hematocrit of 51%. Which of the following statements by the nurse reflects the most appropriate interpretation of this information? - "The infant's body is compensating for tissue hypoxia by increasing RBC production." 28. A nurse is teaching the parents of a newborn who has congenital hypothyroidism about care of their child. Which of the following should the nurse recommend to the parents? - Life-long administration of thyroid hormone 29. A nurse is caring for a child who has epistaxis. Which of the following actions would be the most appropriate for the nurse to take? . - Apply a cold cloth to bridge of nose 30. A nurse is caring for a 10-year-old child who is postoperative abdominal surgery and was medicated 6 hr ago. When assessing the child, the nurse finds the child quiet and not interacting with family. Which of the following is an appropriate nursing action? - Assess the child's need for pain medication 31. A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions should the nurse recognize as appropriate in the care of this child? Monitoring blood pressure every 4 hr 32. A nurse at the immunization clinic is preparing to administer injections to a 5- year-old child. Which of the following is the appropriate injection for the nurse to administer? - Diphtheria 33. A nurse is admitting a child who has a possible diagnosis of leukemia. Which of the following tests is the most appropriate for the nurse to consider when confirming a diagnosis of leukemia? - Bone marrow aspiration 34. A 10-month-old infant has been hospitalized four times for a total of 42 days. The nurse notices that the infant does not seem upset when the parents leave. Which of the following should the nurse recognize as an appropriate explanation for this behavior? - Experiencing detachment 35. A nurse is caring for a 6-month-old infant who has colic and vomiting who will be undergoing testing to rule out intussusception. Which of the following would be the appropriate treatment for intussusception? - Barium enema 36. A nurse is caring for a child who has a vesicular rash. The parent asks the nurse what illness can cause the rash. Which of the following is the most appropriate response for the nurse to give? - Varicella 37. A nurse is admitting a child who has an exacerbation of cystic fibrosis. The nurse should expect to find which of the following assessments? - Oxygen saturation of 85% 38. A nurse is admitting a toddler brought to the hospital for circumferential burns. The history given and burn markings do not correlate, therefore, child abuse is suspected. Which of the following should the nurse consider the most important to include in the documentation? - A description of the burns 39. A nurse is caring for a child who is admitted with swollen, painful joints and is diagnosed with rheumatic fever. When educating the child's parent about rheumatic fever, which of the following statements by the nurse would be appropriate? - "It is preceded by a streptococcal infection 40. A nurse is caring for a child who has cerebral palsy who is scheduled for orthopedic surgery. Which of the following strategies should the nurse plan to include in the initial plan of care? . - Facilitate communication with the child by their usual means 41. A nurse is caring for a 6-year-old child who is receiving chemotherapy. The child has a platelet count of 20,000/mm3. Which of the following should the nurse recognize as the appropriate intervention for a child with this platelet count? - Encourage quiet play. 42. A parent calls a primary care provider's office and says her child has a respiratory infection and a temperature of 39° C (102.2° F). The nurse instructs the parent to give the child 240 mg of acetaminophen (Tylenol). The label on the bottle reads 160 mg/5 mL. The nurse should instruct the parent to administer which of the following doses? - 1 1/2 tsp 43. A nurse is planning care for a child who is autistic. Which of the following goals is of primary importance in the care of this child? - To be protected from self-injury 44. A nurse is providing education on poisoning prevention to a group of parents of toddlers. Which of the following would be an appropriate statement by the nurse? - Put all cleaning supplies in a locked cabinet. 45. A nurse is caring for a child who has frequent urinary tract infections. When educating the parent on the prevention of urinary tract infections, which of the following instructions should the nurse include in the teaching? - Teach the child to wipe her perineum from front to back after urinating. 46. A nurse is conducting postoperative teaching for 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 keep my baby's diaper away from the incision." 47. A nurse is caring for a 3-year-old child who has persistent otitis media. When taking the history of the child from her parent, which of the following would be the most appropriate for the nurse to ask regarding the child's recurrent otitis media? - "Does anyone smoke around, or in the same house as, the child?" 48. A nurse is caring for a child who has a diagnosis of iron deficiency anemia. Which of the following instructions would be appropriate for the nurse to give to the parents? - "Give the iron between meals with orange juice." 49. A nurse is caring for four children who have congenital heart disease. Based on the pathophysiology of the disorders, which of the following should the nurse recognize would present with cyanosis? - Transposition of great vessels 50. A nurse is planning care for a 2-day-old infant who has a myelomeningocele. Which of the following nursing measures should take highest priority in the immediate postoperative period? - Measure the head circumference every shift. A nurse is assessing a child who has a congenital heart defect. The nurse should recognise that which of the following defects is associate with increased pulmonary blood flow? Patient ductus arteriosus A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions should the nurse take? Obtain a daily weight A nurse is providing teaching to the parent of a school-age child who has pediculosis capitis. Which of the following instructions should the nurse include in the teaching? "Soak hair brushes in boiling water for 10 minutes." A nurse is providing discharge teaching to the parents of a child who has sickle cell anemia and was hospitalized after experiencing a vasoocclusive crisis. Which of the following instructions should the nurse include in the teaching? increase your child's intake of oral fluids." A nurse is assessing an infant who has hydrocephalus. Which of the following clinical manifestations should the nurse expect? Separated cranial sutures A nurse on a pediatric unit is receiving change-of-shift report for a group of clients. Which of the following clients should the nurse see first? A child who had a cardlac catheterization using the femoral artery and has blanching of the toes A nurse is reviewing the laboratory values of a school-age child who reports increased bruising. Which of the following laboratory values should the nurse expect? Platelets 120.000/mm3 A nurse is providing teaching to an adolescent who has type 2 diabetes mellitus and a new prescription for metformin. Which of the following instructions should the nurse include in the teaching? "Take the medication at the same time each day." A nurse is teaching a school-age child and their parents about managing diabetes mellitus during illness. The nurse should determine that the teaching has been effective when the parents indicate they will provide which of the following when the child is ill? Increased fluids A nurse is assessing a toddler who is toilet-trained and has a temperature of 38.5° C (101.3° F). Which of the following findings should the nurse recognize as an indication of a urinary tract infection (UTI)? Incontinence A nurse is assessing an infant who has intussusception. Which of the following manifestations should the nurse expect? Gelatinous red stool A nurse working on an outpatient surgical unit is providing discharge teaching to the parent of a preschooler following placement of tympanoplasty tubes. The parent asks the nurse, "What should I do if the tubes fall out?" Which of the following responses should the nurse make? Notify the provider that the tubes have fallen out A nurse is teaching the parents of a toddler about strategies to manage temper tantrums. Which of the following instructions should the nurse include in the teaching? "Establish a structured daily routine for the child." A nurse is assessing a child who has received the first 50 mL of a blood transfusion. Which of the following findings indicates that the child might be experiencing an air embolism? Sharp pain in middle of the chest A nurse is caring for a child who has cancer and is receiving chemotherapy. The parent tells the nurse that they want to discontinue treatment and take the child home. Which of the following responses should the nurse make? " What are your reasons for making this decision today?" A nurse is providing teaching to the parent of a child who has a new prescription for methylphenidate. which of the following instructions should the nurse include? Administer the second dose of the medication at lunch time. A nurse is providing discharge teaching to the parent of a school-age child who has pharyngitis caused by group A B-hemolytic streptococci (GABHS). Which of the following instructions should the nurse include in the teaching? (Select all that apply.) bm. ." "Provide your child with their own towel for drying their face and hands at home. "Replace your child's toothbrush 24 hours after beginning antibiotic therapy." "Your child can return to school 24 hours after their first does of antibiotics." A nurse is caring for a child who is experiencing status asthmaticus. Which of the following actions should the nurse take first? Apply humidified oxygen. A nurse is caring for a school-age child who has a prescription for amoxicillin 320 mg PO every 8 hr for 10 days. Available is amoxicillin suspension 400 mg/5 mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) Answer: 4 mL A charge nurse is assisting a newly licensed nurse with the preoperative assessment of a 2-year-old child who has a Wilms' tumor. Which of the following actions by the newly licensed nurse indicates an understanding of the needed care? Measuring the child's abdominal circumference A nurse is completing an assessment following suctioning of a child who has a tracheostomy. Which of the following findings should, the nurse identify as an indication that the procedure has been effective? Clear breath sounds A nurse is instilling otic drops into an 18-month-old child's ears. Which of the following methods should the nurse use? Pull the pinna down and back. A nurse is admitting a child who has bacterial meningitis. Which of the following actions should the nurse take first? Initiate antibiotic therapy for the child. A nurse is providing teaching to the parent of an infant about car seat safety. Which of the following statements by the parent indicate an understanding of the teaching? "I should place the car seat rear-facing until my baby is 2 years old." A nurse is creating a plan of care for a child who is awake and responsive following an acute head injury. Which of the following interventions should the nurse include? . Initiate seizure precautions for the child. A nurse in the emergency department is caring for a preschooler who has epiglottitis. Which of the following actions should the nurse take? Initiate droplet precautions for the child 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? The infant does not roll over from his abdomen to his back. A school nurse is assessing the visual acuity of a school-age child. Which of the following findings indicate that the child should be evaluated for strabismus? Movement of the uncovered eye during a cover test A nurse is providing discharge teaching to the parents of a 6-month-old infant following a surgical procedure to repair a hypospadias. Which of the following instructions should the nurse include in the teaching? Avoid giving the infant a tub bath until the stent is removed. Answer: A nurse is providing teaching to an adolescent who has a new prescription for cefazolin. For which of the following adverse effects should the nurse instruct the adolescent to monitor and report to the provider? Urticaria A nurse is assessing a 4-year-old child following a surgical procedure. Which of the following pain rating scales should the nurse use? Oucher pain rating scale A school nurse is assessing a child who fell from playground equipment and landed head-first. Which of the following manifestations should the nurse recognize as indicating the presence of increased intracranial pressure? Report of diplopla A nurse is assessing a child who has acute kidney injury. Which of the following clinical manifestations should the nurse expect? Edema a home health nurse is providing teaching about post-seizure management to the parents of a school-age child who has epilepsy, what should be included - record the length and character of the child's postictal period following a seizure - call for emergency medical services if the size of the child's pupils are unequal after the seizure a nurse is assessing a 3yr old preschooler at a well-child visit, what developmental tasks should be expected uses primarily two-word phrases a nurse is teaching the parents of a toddler about strategies to manage temper tantrums, what instructions should the nurse include in the teaching to establish a structured daily routine for the child a nurse in a pediatric clinic is discussing the physiology of Reye syndrome with a newly licensed nurse, what statements by the newly licensed nurse indicate an understanding of the disorder Reye's syndrome causes fatty changes in the liver a nurse is assessing a child who has received the first 50 mL of a blood transfusion, what findings indicate the child may be experiencing an air embolism sharp pain in the middle of the chest a school nurse is assessing the visual acuity of a school-age child, what finding indicates that the child should be evaluated for strabismus movement of the uncovered eye during a cover test a nurse is assessing a 6-month-old infant during a well-child visit, what findings should the nurse report to the provider the infant does not roll over from his abdomen to his back a nurse is instilling otic drops into a toddler's ears, what method is used pull the pinna down and back a nurse is providing teaching to the parent of an infant about care seat safety, what statement by the parent indicates an understanding of the teaching I should place the car seat rear facing until my child is 2 a nurse is providing teaching to parents of a school-age child who has ADHD and a new prescription for methylphenidate ER capsules, what responses by the parent indicate an understanding of the nurse's instruction I will inform my child's teacher that he is taking this medication a nurse in a pediatric clinic is performing a history and physical for a toddler who is going to receive an MMR immunization, which indicates that it should be withheld receiving prednisone for nephrotic syndrome a nurse is providing teaching to a mother who plans to breastfeed her 3-day-old infant, what info should the nurse include in the teaching your baby will need a follow-up evaluation by her provider within the next 3 days a nurse is assessing a toddler who is toilet-trained and has a temperature of 38.5/101.3, what findings should the nurse suspect a UTI incontinence a nurse is caring for a school-age child who has hemophilia and reports increased bruising, what lab values explain the finding plt count 120,000 a nurse is preparing a teaching plan for the parent of a school-age child who has asthma, the nurse should include what manifestation as an "exacerbation" of asthma hacking, non-productive cough a nurse is providing discharge teaching to the parents of a 6-month-old infant following a surgical procedure to repair hypospadias, what instructions should the nurse include in the teaching avoid giving the infant a tub bath until the stent is removed a nurse is assessing an infant who has intussusception, what manifestation is expected gelatinous red stool a nurse is caring for a school-age child who has metastatic osteosarcoma, the child asks the nurse "am I going to die?", what should the nurse respond "It sounds like you are worried. tell me what you have been told" a nurse is caring for an infant who has GERD, what action should the nurse take to avoid regurgitation thicken the pt's formula and avoid giving the pt citrus juices position the child with the head elevated after meals a nurse is providing teaching to an adolescent who has a new prescription for cefazolin, what adverse effect should the nurse monitor for and report to the physician urticaria a nurse is caring for a child who has cancer and is receiving chemo, the parent tells the nurse that she wants to d/c treatment and take the child home, what responses should the nurse make tell me more about your reasons for making this decision today a charge nurse is assisting a newly licensed nurse with the preoperative assessment of a 2-year-old child who has a Wilm's tumor, what actions by the newly licensed nurse require intervention from the charge nurse palpating the child's abdomen a nurse is assessing a child who has sickle cell anemia and is experiencing a Vaso occlusive crisis, what manifestations should the nurse expect pain a nurse is providing teaching to the parents of a school-age child who has pediculosis capitis, what instruction should be included soak her brushes in boiling water for 10min a nurse is caring for a child who has acute glomerulonephritis without edema, what action should the nurse take to obtain daily weight a nurse is reviewing the medical record of a 16 yr old brought in by his parents to receive a physical, the record indicates he received his last immunization 10 years ago, what immunizations should the nurse expect to administer to the adolescent Tdap a nurse is caring for a child who has a congenital heart defect, the nurse should recognize which of the following defects is associated with increased pulmonary blood flow PDA a nurse is providing teaching to the parent of a preschooler about health promotion, what response by the parent indicates an understanding of the teaching I should encourage my child to have 1 hour of physical activity each day a nurse is admitting a child who has bacterial meningitis, what actions should the nurse take first initiate antibiotic therapy for the child a nurse is assessing a toddler who has infective endocarditis, what findings should the nurse expect new heart murmur a nurse is suctioning the tracheostomy of a child, what assessment findings indicate the effectiveness of the procedure clear breath sounds a nurse is assessing a child who has acute renal failure, what clinical manifestations are expected edema a nurse is developing a plan of care for a 4yr old who has hemophilia and is experiencing acute hemarthrosis, what interventions should the nurse include in the plan place ice packs on the affected joints a nurse is providing discharge teaching to the parent of a school-age child who has an infection of the throat caused by group A beta-hemolytic streptococci, what instructions should the nurse give to the parent continue to administer the prescribed antibiotic for 10d give your child acetaminophen or children ibuprofen for fever a nurse is providing teaching to the parent of a child who has a new prescription for methylphenidate, what instruction should the nurse include to administer the second dose of the medication at lunchtime a nurse working on an outpatient surgical unit is providing discharge teaching to the parent of a preschooler following the placement of tympanoplasty tubes. the parent asks, what should I do if the tubes fall out. What should the nurse instruct? notify the provider that the tubes have fallen out a nurse in the emergency department is caring for a preschooler who has epiglottitis, what action should the nurse take initiate droplet precautions for the child a nurse is providing discharge teaching to the parents of a child who has sickle cell anemia and was hospitalized after experiencing a Vaso occlusive crisis. what instructions should the nurse include in the teaching increase your child's intake of oral fluids a nurse is caring for a child who has bacterial meningitis, what action should the nurse take initiate seizure precautions a nurse is assessing a 12m old infant who is immediately postop hernia repair surgery, what pain measurement tools should the nurse use to determine if the infant is experiencing pain FLACC a nurse is teaching a school-age child and her parents about managing diabetes mellitus during illness, the nurse determines teaching has been effective when they indicate they will provide which of the following when the child is ill increase fluids a nurse is caring for a toddler who drinks 950mL (32oz) of milk per day and has a poor appetite, the nurse should identify that the toddler is at risk for iron deficiency anemia a nurse is providing teaching to an adolescent who has type 2 diabetes mellitus and a new prescription for metformin, what instruction should the nurse include take the medication at the same time each day a school nurse is assessing a child who fell from playground equipment and landed headfirst, what clinical manifestations should the nurse recognize as indicating increased intracranial pressure report of diplopia a nurse is assessing an infant who has hydrocephalus, what clinical manifestations should the nurse expect separated cranial sutures a nurse is teaching the parent of an infant about preventing SIDS, what following statement should the nurse make you should put your infant in bed with a pacifier a nurse in the ED is creating a plan of care for a child who has an acute head injury following a fall from playground equipment, what interventions should the nurse include to initiate seizure precautions for the child a nurse is caring for a 4m old infant who is immediately postop following cleft palate repair, what intervention should the nurse take apply elbow restraints to the infant a nurse is assessing a 5-month-old infant during a well-child visit, what finding should the nurse report to the provider the infant does not make consonant sounds. STOP!!!! A nurse in an emergency department is caring for a 4-year-old child who has burns to the neck and face following a house fire. Which of the following actions should the nurse take first? Determine the child's breathing pattern. A nurse is providing teaching to the parent of a 2-year-old toddler about nutrition. Which of the following statements by the parent indicates an understanding of the teaching? "My child should consume 1,000 calories per day." A nurse is preparing to obtain an antistreptolysin O (ASO) titer from a child who has acute glomerulonephritis. The child's parent asks the nurse to explain the purpose of the test. Which of the following responses should the nurse make? "The test shows us if your child had a recent strep infection." A nurse is providing nutritional teaching to an adolescent client who has celiac disease. Which of the following breakfast foods should the nurse recommend? Scrambled eggs A nurse is providing teaching to an adolescent who has scoliosis and a new prescription for a Boston brace. Which of the following responses by the adolescent indicates an understanding of the teaching? I can take my brace off for about an hour daily to shower A nurse is providing discharge teaching to the parent of a school-age 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 every day for sores A nurse is assessing a toddler who has measles (rubeola). Which of the following findings should the nurse expect? Koplik spots A nurse is admitting a child who has Wilms' tumor. Which of the following actions should the nurse take? Put a "no abdominal palpation" sign over the child's bed. A nurse is providing dietary teaching to the parent of a child who has cystic fibrosis. Which of the following dietary recommendations should the nurse make? Increase the child's protein intake. A clinic 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 understanding of the teaching? I will add rice cereal to my baby's feedings. A nurse is caring for an infant following surgical repair of a cleft lip and palate. Which of the following actions should the nurse take? Suction the infant gently with a bulb syringe PRN A nurse in an emergency department is assessing a school-age 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 A nurse is teaching about clinical manifestations of tracheomalacia to a parent of an infant who had tracheoesophageal fistula repair as a newborn. Which of the following findings should the nurse include in the teaching? Barking cough A nurse is caring for a 12-month-old infant following surgical repair of a cleft palate. The nurse should plan to feed the infant using which of the following instruments? Cup A nurse is reviewing the laboratory report of a toddler who is receiving chemotherapy for leukemia. Which of the following laboratory values should the nurse report to the provider? Hg 6g/dL A 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 epiglottitis? Drooling A nurse is assessing pain in a 3-year-old child following a tonsillectomy. Which of the following rating scales should the nurse use to determine the child's pain level? FACES A nurse is teaching a newly hired nurse about the care of 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 A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following findings is the nurse's priority? Frequent swallowing A nurse is caring for a 6-week-old infant following a pyloromyotomy. Which of the following forms of feeding should the nurse anticipate for the infant 6 hr after the procedure? Small, frequent bottle feedings of electrolyte solution A nurse is providing teaching to an adolescent who has a fiberglass arm cast. Which of the following instructions should the nurse include in the teaching? Place a plastic bag over the cast when showering A 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 A nurse is teaching the parent of a preschool-age 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 A nurse is reviewing the laboratory report of a 2-year-old child who has diarrhea and has been vomiting for 24 hr. Which of the following findings should the nurse report to the provider? Potassium 2.5 mEq/L A nurse is caring for a child who is in skeletal traction. Which of the following actions is the nurse's priority? Encourage the child to use an incentive spirometer A home health nurse is developing a plan of care for the parents of a toddler who has hemophilia. Which of the following instructions should the nurse include in the plan? Inspect the toddler's toys for sharp edges A nurse is assessing a child who has a ventricular septal defect. Which of the following findings should the nurse expect? Murmur at the left sternal border A nurse is assessing a 6-month-old infant following a cardiac catheterization. Which of the following findings should the nurse report to the provider? BP 86/40 mm Hg A nurse is teaching an adolescent who has asthma about how to use a peak expiratory flow meter (PEFM). Which of the following responses by the adolescent indicates an understanding of the teaching? I will record the highest reading of three attempts. A 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 A nurse is creating a plan of care for a child who has leukopenia secondary to chemotherapy. Which of the following interventions should the nurse include in the plan? Monitor the child for increased temperature A nurse is providing teaching to the parents of a school-age child who has type 1 diabetes mellitus about management of hypoglycemia. Which of the following responses by the parents indicates an understanding of the teaching? I will make sure my child drinks 240 mL (8 oz) of milk as soon as possible A nurse is caring for an 8-year-old child who has acute glomerulonephritis. Which of the following findings should the nurse expect? Periorbital edema A nurse is providing teaching about immunizations 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 A nurse is providing teaching to the parents of an infant who has acute otitis media about how to administer antibiotic eardrops. Which of the following instructions should the nurse include? Massage the anterior area of the infant's ear following administration A nurse is reviewing the laboratory results 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 A nurse is caring for a child who has a possible intussusception. The parents of the child ask the nurse how the diagnosis is made. Which of the following responses should the nurse make? An abdominal ultrasound will confirm the pocket in the intestine A nurse is 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 (4 lb) A nurse is planning care for an adolescent who has sickle cell anemia and is experiencing a vasoocclusive crisis. Which of the following interventions should the nurse include in the plan? Maintain the child on bed rest A nurse is teaching a school-age child and his parents how to self-administer insulin. Which of the following actions should the nurse take first? Demonstrate the injection technique on an orange. A nurse is planning care for a newly admitted school-age child who has generalized seizure disorder. Which of the following interventions should the nurse plan to include? Ensure that a padded tongue blade is at the child's bedside Allow the child to play video games on a tablet computer. Allow the child to take a tub bath independently. Ensure the oxygen source is functioning in the child's room Ensure the oxygen source is functioning in the child's 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? "You should offer your child high-protein meals and snacks throughout the day." "You should decrease your child's dietary fat intake to less than 10% of their caloric intake." "You should restrict your child's calorie intake to 1,200 per day." "You should give your child a multivitamin once weekly." "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? "You may bathe your infant in an infant bathtub when you go home." "Apply hydrocortisone cream to your infant's penis daily." "You should clamp your infant's stent twice daily." "Allow the stent to drain directly into your infant's diaper." "Allow the stent to drain directly into your infant's 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? Decreased edema Increased abdominal girth Decreased appetite Increased protein in the urine 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? A toddler who has a concussion and an episode of forceful vomiting An adolescent who has infective endocarditis and reports having a headache An adolescent who was placed into halo traction 1 hr ago and reports pain as 6 on a scale of 0 to 10 A school-age child who has acute glomerulonephritis and brown-colored urine 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 a lower leg cast applied 24 hr ago. The nurse should instruct the guardians to report which of the following findings to the provider? Capillary refill time less than 2 seconds Restricted ability to move the toes Swelling of the casted foot when the leg is dependent Pedal pulse +3 bilateral 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? (Click on the audio button to listen to the clip.) Wheezes Crackles Pleural friction rub Rhonchi 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? Furosemide Captopril Regular insulin Potassium chloride 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? The child should be able to stand on the balls of their feet when sitting on the bike. The child should ride their bike 2 feet to the side of other bike riders. The child should wear dark-colored clothing with a fluorescent stripe when riding at night. The child should ride the bike facing traffic when it is necessary to ride in the street. 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? Wrist Great toe Index finger Heel 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 in an emergency department is caring for a school-age child who has epiglottitis. Which of the following actions should the nurse take? Obtain a throat culture from the child. Monitor the child's oxygen saturation. Put a warm mist humidifier in the child's room.