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1. A nurse is contributing to the plan of care for a preschooler who has moder-
ate partial-thickness burns on both lower extremities. Which of the following
interventions should the nurse recommend?
Ans >> : Ensure the child receives pain medication 30 to 45 min prior to therapy.
Rationale The nurse should ensure that the preschooler receives pain medication
30 to 45 min prior to physical therapy sessions. The nurse should monitor the
child's pain levels and treat them as needed. This will minimize or eliminate pain
from moving tight skin at joints, which will encourage the child to participate in
physical therapy. If the child is in pain during therapy, it will be a challenge to get
the child to participate in future sessions.
2. A nurse is assisting with care for an adolescent client who has asthma and a
new prescription for albuterol by metered-dose inhaler. Which of the following
statements by the client indicates that they might be experiencing an adverse
effect of albuterol?
Ans >>: "My heart feels like it's fluttering after taking my medication,"
Rationale The nurse should identify that the client might be experiencing
palpitations or tachycardia, common adverse effects of albuterol.
,3. A nurse in a provider's office is collecting data from an adolescent who has
juvenile idiopathic arthritis and has been taking ibuprofen daily for the last 6
months. Which of the following client statements should the nurse report to
the provider?
Ans >>: "Inoticed some blood in my stool this morning."
Rationale The nurse should identify that bloody stools are an adverse effect of
long-term therapy with ibuprofen. The nurse should question the adolescent
regarding a new onset of abdominal pain and should report the client's statement
to the provider.
4. A nurse is reinforcing teaching with the parent of a child who has diabetes
mellitus. The parent asks the nurse how to minimize the child's pain when
monitoring blood glucose levels. Which of the following statements by the
parent indicates an understanding of the teaching?
Ans >>: "My child should hold their finger under warm water before obtaining a
sample.
Rationale Holding the finger under warm water will'promote blood flow to the
finger, making the puncture less painful.
5. A nurse is reinforcing teaching with the parent of a child who has a bacterial
upper respiratory infection. Which of the following statements by the parent
indicates an understanding of the teaching?: "I will keep my child's towels
separate from those of the rest of the family."
, Rationale The nurse should identify that a child who has an upper respiratory
infection should use separate towels, utensils, and cups to prevent the infection
from spreading.
6. A nurse is contributing to the plan of care for a child who has nephrotic
syndrome and a prescription for corticosteroids. Which of the following inter-
ventions should the nurse recommend?
Ans >>: Provide a low-sodium diet.
Rationale The nurse should recommend providing the child with a low-sodium diet
to decrease edema associated with nephrotic syndrome.
7. A nurse is collecting data from a child who recently experienced a psy-
chomotor seizure. Which of the following findings should the nurse expect?-
Ans >>: Amnesia
Rationale The nurse should identify that amnesia is an expected manifestation afte
a seizure. Children often do not remember the seizure activity.
8. A nurse is collecting data from a 5-month-old infant who is postoperative
following umbilical hernia repair. Which of the following measures should the
nurse use to evaluate the infant's pain level?
Ans >>: FLACC pain rating scale
Rationale The nurse should use the FLACC pain rating scale to evaluate this
infant's pain level following outpatient surgery to repair an umbilical hernia. The
FLACC scale is a postoperative pain rating tool used for children ranging from 2
months old to 7 years old. The acronym stands for Face, Legs, Activity, Cry, and
Consolability. The scoring ranges from 0, indicating "no pain behaviors" to 10,
indicating "most possible pain behaviors."
9. A nurse is assisting in the admission of a 9-month-old infant who has
gastroenteritis with vomiting and diarrhea. Which of the following findings
is the nurse's priority? (Click on the exhibit tabs for additional information
about the client. There are three tabs that contain separate categories of
data.)