A nurse is contributing to the plan of care for a preschooler who has moderate partial-
thickness burns on both lower extremities. Which of the following interventions should the
nurse recommend? - ANSWER Ensure the child receives pain medication 30 to 45 min
prior to therapy.
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.
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? -
ANSWER "My heart feels like it's fluttering after taking my medication,"
The nurse should identify that the client might be experiencing palpitations or tachycardia,
common adverse effects of albuterol.
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? -
ANSWER "Inoticed some blood in my stool this morning."
1
,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.
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? - ANSWER "My child should hold their finger under warm water before
obtaining a sample.
Holding the finger under warm water will'promote blood flow to the finger, making the
puncture less painful.
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? - ANSWER "I will keep my child's towels separate from
those of the rest of the family."
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.
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 interventions should the nurse
recommend? - ANSWER Provide a low-sodium diet.
The nurse should recommend providing the child with a low-sodium diet to decrease edema
associated with nephrotic syndrome.
A nurse is collecting data from a child who recently experienced a psychomotor seizure.
Which of the following findings should the nurse expect? - ANSWER Amnesia
2
, The nurse should identify that amnesia is an expected manifestation after a seizure. Children
often do not remember the seizure activity.
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? - ANSWER FLACC pain rating scale
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."
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.) - ANSWER Potassium level
When using the urgent vs. nonurgent approach to client care, the nurse should identify that
the priority finding is a potassium level of 3.2 mEq/L because this is below the expected
reference range of 4.1 to 5.3 mEq/L for a 9-month-old infant. Hypokalemia, or a decreased
potassium level, impacts the ability of smooth muscles to contract and can lead to cardiac
arrythmias. Therefore, the nurse should identify this as the priority finding and notify the
provider.
A nurse is caring for a toddler who has a respiratory illness and a temperature of 39.3° C
(102.7" F). Which of the following actions should the nurse take to reduce the toddler's
temperature? - ANSWER Remove the toddler's extra clothing.
The nurse should remove the toddler's extra clothing after administering an antipyretic to
reduce the toddler's temperature.
3
thickness burns on both lower extremities. Which of the following interventions should the
nurse recommend? - ANSWER Ensure the child receives pain medication 30 to 45 min
prior to therapy.
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.
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? -
ANSWER "My heart feels like it's fluttering after taking my medication,"
The nurse should identify that the client might be experiencing palpitations or tachycardia,
common adverse effects of albuterol.
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? -
ANSWER "Inoticed some blood in my stool this morning."
1
,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.
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? - ANSWER "My child should hold their finger under warm water before
obtaining a sample.
Holding the finger under warm water will'promote blood flow to the finger, making the
puncture less painful.
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? - ANSWER "I will keep my child's towels separate from
those of the rest of the family."
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.
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 interventions should the nurse
recommend? - ANSWER Provide a low-sodium diet.
The nurse should recommend providing the child with a low-sodium diet to decrease edema
associated with nephrotic syndrome.
A nurse is collecting data from a child who recently experienced a psychomotor seizure.
Which of the following findings should the nurse expect? - ANSWER Amnesia
2
, The nurse should identify that amnesia is an expected manifestation after a seizure. Children
often do not remember the seizure activity.
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? - ANSWER FLACC pain rating scale
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."
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.) - ANSWER Potassium level
When using the urgent vs. nonurgent approach to client care, the nurse should identify that
the priority finding is a potassium level of 3.2 mEq/L because this is below the expected
reference range of 4.1 to 5.3 mEq/L for a 9-month-old infant. Hypokalemia, or a decreased
potassium level, impacts the ability of smooth muscles to contract and can lead to cardiac
arrythmias. Therefore, the nurse should identify this as the priority finding and notify the
provider.
A nurse is caring for a toddler who has a respiratory illness and a temperature of 39.3° C
(102.7" F). Which of the following actions should the nurse take to reduce the toddler's
temperature? - ANSWER Remove the toddler's extra clothing.
The nurse should remove the toddler's extra clothing after administering an antipyretic to
reduce the toddler's temperature.
3
