A nurse is creating a plan of care for a school-age child who has heart disease and has developed
heart failure. Which of the following interventions should the nurse include in the plan?
a. provide small, frequent meals for the child
A nurse is teaching the parent of an infant who has Pavlik harness for the treatment of
developmental dysplasia of the hip. The nurse should identify that which of the following
statements by the parent indicates an understanding of the teaching?
d. "I will place my infant's diaper under the harness straps."
A nurse is planning care for a school-age child who is in the oliguric phase of acute kidney injury
(AKI) and has a sodium level of 129 meq/L. Which of the following interventions should the
nurse include in the plan?
d. initiate seizure precautions for the child
A nurse is assessing a school-age child immediately following a perforated appendix repair.
Which of the following findings should the nurse expect?
b. absence of peristalsis
A nurse is preparing an adolescent for a lumbar puncture. Which of the following actions should
the nurse take?
b. apply topical analgesic cream to the site 1hr prior to the procedure
A nurse is caring for a school-age child who is receiving cefazolin via intermittent IV bolus. The
child suddenly develops diffuse flushing of the skin and angioedema. After discontinuing the
medication infusion, which of the following medications should the nurse administer first?
b. epinephrine
A nurse is teaching the parent of a preschooler about ways to prevent acute asthma attacks.
Which of the following statements by the parent indicates an understanding of the teaching?
d. "I will keep my child indoors when I mow the yard."
A nurse is providing dietary teaching to the parent of a school-age child who has celiac disease.
The nurse should recommend that the parent offer which of the following foods to the child?
d. white rice
A nurse is reviewing the laboratory report of a school-age child who is experiencing fatigue.
Which of the following findings should the nurse recognize as an indication of anemia?
a. hematocrit 28%
A nurse is preparing to collect a sample form a toddler for a sickle-turbidity test. Which of the
following actions should the nurse plant to take?
b. perform a finger stick
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, A nurse is assessing a school-age child who has meningitis. Which of the following findings is
the priority for the nurse to report to the provider?
b. petechiae on the lower extremities
A nurse is assessing an infant who has a ventricular septal defect. Which of the following
findings should the nurse expect?
a. loud, hard murmur
A nurse is creating a plan of care for an infant who has an epidural hematoma form a head injury.
Which of the following interventions should the nurse include in the plan?
d. implement seizure precautions for the infant
A nurse is caring for an adolescent who received a kidney transplant. Which of the following
findings should the nurse identify as an indication the adolescent is rejecting the kidney?
b. serum creatinine 3.0 mg/dL
A nurse in an emergency department is performing a physical assessment on a 2 week old male
newborn. Which of the following findings is priority for the nurse to report to the provider?
c. substernal retractions
A hospice nurse is caring for a preschooler who has a terminal illness. One of the preschooler's
parents tells the nurse that they cannot cope anymore and are thinking about moving out of the
house. Which of the following statements should the nurse make?
d. "Let's talk about some of the ways you have handled previous stressors in your life."
A nurse is reviewing the laboratory report of a 7-year-old child who is receiving chemotherapy.
Which of the following laboratory values should the nurse report to the provider?
a. hgb 8.5g/dL
A nurse is caring for a 15 year old client who is married and is scheduled for a surgical
procedure. The client asks, "Who should sign my surgical consent?" Which of the following
responses should the nurse make?
a. "You can sign the consent form because you are married"
A nurse is assessing a 4 year old child at a well-child visit. Which of the following
developmental milestones should the nurse expect to observe?
c. cuts an outlined shape using scissors
A nurse is caring for an infant who has respiratory syncytial virus (RSV). Which of the following
actions should the nurse implement for a infection control?
a. have a designated stethoscope in the infant's room.
A nurse in an emergency department is caring for a school-age child who has appendicitis and
rates their pain as 7 on a 0-10 scale. Which of the following actions should the nurse take?
b. give morphine 0.05mg/kg IV
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