RN Nursing Care of Children Online Practice 2019 A with NGN 60 Q&A

1. A nurse is teaching the parent of an infant about "Give the infant ways to prevent sudden infant death syndrome (SIDS). a pacifier at bed- Which of the following instructions should the nurse include? "Place the infant in a prone position to sleep." "Allow the infant to sleep on a large pillow." "Use a soft mattress in the infant's crib." "Give the infant a pacifier at bedtime." 2. A nurse in an emergency department is caring for a school-age child who is experiencing an anaphylactic reaction. Which of the following is the priority action by the nurse? Elevate the head of the child's bed. Insert a large bore IV catheter for the child. Determine the allergen that caused the child's reac- tion. Administer epinephrine IM to the child. time." The nurse should inform the parent that protective fac- tors against SIDS include breast- feeding and the use of a pacifier when the infant is sleeping. Administer epi- nephrine IM to the child. When using the urgent vs. nonur- gent approach to client care, the nurse should de- termine that the priority action is administering epi- nephrine IM to the child. During an anaphylactic re- action, histamine release caus- es bronchocon- striction and va- sodilation. This is an emergency be- cause ultimately this causes de- creased blood re- turn to the heart. 3. A nurse is caring for a preschooler whose father is going home for a few hours while another relative stays with the child. Which of the following statements should the nurse make to explain to the child when their father will return? "Your daddy will be back at 7 p.m." "Your daddy will be back after he takes care of your brother." "Your daddy will be back in the morning." "Your daddy will be back after you eat." 4. A nurse is reviewing the laboratory report of an infant who is receiving treatment for severe dehydration. The nurse should identify that which of the following lab- oratory values indicates effectiveness of the current treatment? Potassium 2.9 mEq/L Sodium 140 mEq/L Urine specific gravity 1.035 BUN 25 mg/dL "Your daddy will be back after you eat." Preschoolers make sense of time best when they can associate it with an expected daily routine, such as meals and bedtime. Therefore, the child comprehends time best when it is explained to them in relation to an event they are familiar with, such as eating.. Sodium 140 mEq/L The nurse should identify that a sodi- um level of 140 mEq/L is within the expected refer- ence range of 134 to 150 mEq/L and indicates the cur- rent treatment reg- imen the infant is receiving for dehy- dration is effective. 5. 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? Provide small, frequent meals for the child. Schedule time in the play room for the child. Weigh the child weekly. Maintain the child in a supine position. 6. A nurse is admitting a school-age child who has pertussis. Which of the following actions should the nurse take? Place the child in a room with positive-pressure air- flow. Place the child in a room with negative-pressure air- flow. Initiate contact precautions for the child. Initiate droplet precautions for the child. 7. A school nurse is assessing an adolescent who has scoliosis. Which of the following findings should the Provide small, fre- quent meals for the child. The metabolic rate of a child who has heart failure is high because of poor cardiac func- tion. Therefore, the nurse should pro- vide small, fre- quent meals for the child because it helps to con- serve energy. Initiate droplet pre- cautions for the child. The nurse should initiate droplet pre- cautions for a child who has pertussis, also known as whoop- ing cough. Per- tussis is transmit- ted through con- tact with infected large-droplet nu- clei that are sus- pended in the air when the child coughs, sneezes, or talks. A unilateral rib hump nurse expect? Increase in anterior convexity of the lumbar spine Increased curvature of the thoracic spine Lateral flexion of the neck A unilateral rib hump 8. A nurse is providing teaching to the parent of a school-age child who has a new prescription for oral nystatin for the treatment of oral candidiasis. Which of the following instructions should the nurse include? "Shake the medication prior to administration." "Provide the medication through a straw." "Rinse the child's mouth with water immediately after giving the medication." "Mix the medication with applesauce if the child dis- likes the taste." 9. A school nurse is preparing to administer atomox- etine 1.2 mg/kg/day PO to a school-age child who When assess- ing an adoles- cent for scoliosis, the school nurse should expect to see a unilateral rib hump with hip flex- ion. This results from a lateral S- or C-shaped cur- vature to the tho- racic spine result- ing in asymme- try of the ribs, shoulders, hips, or pelvis. Scoliosis can be the result of a neuromuscu- lar or connective tissue disorder, or it can be congeni- tal in nature. "Shake the med- ication prior to ad- ministration." The nurse should instruct the parent to shake the med- ication prior to ad- ministration to dis- perse the medica- tion evenly within the suspension. The nurse should administer atom- weighs 75 lb. Available is atomoxetine 40 mg/capsule. oxetine 1 capsule How many capsules should the nurse administer per PO each day. day? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) 10. 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? Hematocrit 28% Hemoglobin 13.5 g/dL WBC count 8,000/mm3 Platelets 250,000/mm3 11. A nurse is interviewing the parent of an 18-month-old toddler during a well-child visit. The nurse should identify that which of the following findings indicates a need to assess the toddler for hearing loss? The toddler has a vocabulary of 25 words. The toddler developed a mild rash following a recent varicella immunization. The toddler's Moro reflex is absent. The toddler received tobramycin during a hospitaliza- tion 2 weeks ago. Hematocrit 28% The nurse should recognize that this hematocrit level is below the expected refer- ence range of 32% to 44% for a school-age child. The child can exhibit fa- tigue, lightheaded- ness, tachycardia, dyspnea, and pal- lor due to the decreased oxy- gen-carrying ca- pacity. The toddler re- ceived tobramycin during a hospital- ization 2 weeks ago. The nurse should identify tobramycin as an aminoglyco- side, which is an ototoxic medica- tion that can cause mild to moderate hearing loss, and should assess the 12. A nurse in a provider's office is caring for a preschool- er. Nurses' Notes 0915:Guardians report that lately the child has had severe itching and is breaking out with sores on their eyebrows, wrists, and ankles. The "sores started to bleed." Guardians report no relief with application of the topical hydrocortisone cream.0930:Child is alert. Multiple small erythematous papules with some scal- ing noted on the child's eyebrows, forearms, and lower legs bilaterally.1015:Provider in to evaluate the child. Discharge to home after medication administra- tion of new prescriptions and discharge teaching for atopic dermatitis. Medical History Family history of atopic dermatitis Medication Administration Record 1000:Loratadine (oral solution) 5 mg PO daily. Ad- minister first dose now prior to discharge.Tacrolimus 0.03% ointment. Apply thin layer to affected areas twice daily; rub in gently and completely.Return to primary care provider in 1 to 2 weeks for evaluation. Which of the following statements by a guardian indi- cate that the discharge teaching was effective? Select all that apply. "We should apply a skin emollient immediately after bathing our child." "We should keep our child's fingernails tri toddler for a hear- ing impairment. "We should ap- ply a skin emol- lient immediately after bathing our child" is correct. An emollient is an oil that mois- turizes the skin and should be ap- plied immediately after bathing while the skin is damp to prevent dry- ing. Therefore, this statement by the guardian indicates the teaching has been effective "We should keep our child's fin- gernails trimmed short" is correct. The child's finger- nails and toenails should be kept short, trimmed, and filed to prevent scratch- ing with sharp edges. Therefore, this statement by the guardian indi- cates the teaching has been effective. g. 13. A nurse is caring for a school-age child who is re- ceiving cefazolin via intermittent IV bolus. The child suddenly develops diffuse flushing of the skin and angioedema. After discontinuing the medication infu- sion, which of the following medications should the nurse administer first? Prednisone Epinephrine Diphenhydramine Albuterol "We should use a mild detergent for our laundry" is cor- rect. The use of mild detergents for laundry helps pre- vent allergens and itching. Therefore, this statement by the guardian indi- cates the teaching has been effective. Epinephrine This child is most likely experiencing an anaphylactic reaction to the ce- fazolin. According to evidence-based practice, the nurse should first ad- minister epineph- rine to treat the anaphylaxis. Epi- nephrine is a beta adrenergic ago- nist that stimulates the heart, causes vasoconstriction of blood vessels in the skin and mu- cous membranes, and triggers bron- chodilation in the lungs. 14. A is correct 15. A nurse is reviewing the lumbar puncture results of a school-age child who is suspected of having bacterial meningitis. Which of the following findings should the nurse identify as an indication of bacterial meningi- tis? Decreased cerebrospinal fluid pressure Decreased WBC count Increased protein concentration Increased glucose level 16. A nurse is preparing to collect a sample from a tod- dler for a sickle-turbidity test. Which of the following actions should the nurse plan to take? Obtain a sputum specimen. Perform an Allen test. Perform a finger stick. Obtain a stool specimen. 17. 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 Increased protein concentration The nurse should identify that an increased protein concentration in the spinal fluid is a finding that can indicate bacterial meningitis. Perform a finger stick. The nurse should perform a finger stick on a tod- dler as a compo- nent of the sick- le-turbidity test. If the test is pos- itive, hemoglobin electrophoresis is required to dis- tinguish between children who have the genetic trait and children who have the disease. White rice The nurse should recommend that following foods to the child? Wheat crackers Rye bread Barley soup White rice 18. A nurse in an emergency department is performing a physical assessment on a 2-week-old male newborn. Which of the following findings is the priority for the nurse to report to the provider? Excoriated scrotal area Multiple capillary hemangiomas Depressed posterior fontanel Substernal retractions the parent offer white rice to the child because it is a gluten-free food. The nurse should instruct the par- ent that the child will remain on a lifelong gluten-free diet and the child should not con- sume oats, rye, barley, or wheat, and sometimes lactose deficiency can be secondary to this disease. Substernal retrac- tions When using the airway, breathing, and circulation ap- proach to client care, the nurse should determine that the priority finding to report to the provider is substernal retrac- tions. This find- ing indicates the newborn is expe- riencing increased respiratory effort, which could quick- ly progress to res- piratory failure. 19. A nurse is caring for an adolescent who received a kid- Serum creatinine ney transplant. Which of the following findings should the nurse identify as an indication the adolescent is rejecting the kidney? Negative leukocyte esterase Serum creatinine 3.0 mg/dL Negative urine protein Urine output 40 mL/hr 20. 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? Hgb 8.5 g/dL WBC count 9,500/mm3 Prealbumin 18 mg/dL Platelets 300,000/mm3 3.0 mg/dL Creatinine is a byproduct of pro- tein metabolism and is excreted from the body through the kid- neys. An elevated serum creatinine level, therefore, can be an indica- tion that the kid- neys are not func- tioning. The nurse should identify that the adolescent's serum creatinine level is higher than the expected refer- ence range of 0.4 to 1.0 mg/dL for an adolescent and can indicate rejec- tion of the kidney. Hgb 8.5 g/dL A child receiv- ing chemothera- py is at risk for anemia due to the chemother- apy effects on the blood-forming cells of the bone marrow. The de- velopment of ane- mia is diagnosed through laboratory 21. A nurse in an emergency department is caring for a 4-year-old child who was rescued from a home fire by emergency medical services (EMS History and Physical 4-year-old child was in a house fire and rescued by EMS. Child has partial-thickness and full-thickness burns on their left arm, hand, anterior neck, and upper left side of the anterior chest. Total body surface area (TBSA) estimated to be 18%. testing of hemo- globin and hema- tocrit levels. The nurse should rec- ognize that a he- moglobin level of 8.5 g/dL is below the expected ref- erence range of 10 to 15.5 g/dL for a 7-year-old child and should be reported to the provider. . Partial- and full-thickness burns to the left upper anterior chest and anterior neck is correct. Airway, breathing, and circulation are Child is awake and crying. Lungs are clear bilaterally. the immediate Has a non-productive cough. Graphic Record Temperature 37.7° C (99.9° F)Heart rate 150/minRespi- concerns. Burns to the chest and neck require ratory rate 32/minBlood pressure 100/52 mm HgSaO2 immediate 89% on room air The nurse should identify that which of the following findings require immediate follow-up? Select the 3 findings that require immediate follow-up. Child is awake and crying Partial- and full-thickness burns to the left upper an- terior chest and anterior neck Non-productive cough follow-up due to a concern for inhalation injury. In addition, the edema of the tissue in the neck can compromise the airway and severe burns to the chest can SaO2 89% on room air Heart rate 150/min Temperature 37.7° C (99.9° F) Blood pressure 100/52 mm Hg impede the child's ability to expand their chest during inspiration, causing respiratory distress. SaO2 89% on room air is correct. Airway, breath- ing, and circula- tion are the im- mediate concerns. The nurse should immediately fol- low-up on the low oxygen saturation level. Hypoxia can be a manifesta- tion of respira- tory distress or shock. Therefore, this finding needs immediate atten- tion. Heart rate 150/min is correct. Airway, breathing, and cir- culation are the immediate con- cerns. The nurse should immediate- ly follow-up on the child's increased heart rate. Tachy- cardia is a mani- festation of shock. Children with ma- 22. A nurse in an emergency department is caring for a 4-year-old child whowas rescued from a home fire by emergency medical services (EMS). History and Physical 4-year-old child was in a house fire and rescued by EMS. Child has partial-thickness and full-thickness burns on their left arm, hand, anterior neck, and upper left side of the anterior chest. Total body surface area (TBSA) estimated to be 18%. jor burns can de- velop hypovolemic shock due to fluid loss. Apply sterile gauze soaked with cool 0.9% sodi- um chloride to the burn areas is contraindicated. Applying sterile gauze soaked with cool 0.9% sodi- Child is awake and crying. Lungs are clear bilaterally. um chloride to a Has a non-productive cough. Graphic Record Temperature 37.7° C (99.9° F)Heart rate 150/minRespi- child who has 18% TBSA might cause hypothermia. The ratory rate 32/minBlood pressure 100/52 mm HgSaO2 nurse should cov- 89% on room air Which of the following potential provider prescrip- tions should the nurse identify as anticipated or con- traindicated? For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the child. er the burn with a clean, dry cloth to prevent conta- mination and hy- pothermia. Insert an in- dwelling urinary catheter is antici- pated. Inserting an indwelling urinary catheter is essen- tial and allows for accurate mea- surement of urine output. Urine out- put is an indica- tor of the fluid sta- tus of the child. A child who has ma- jor burns will lose a significant amount of fluid due to increased capil- lary permeability, which increases the risk for hy- povolemic shock. It is important to maintain accurate hourly I&O to man- age fluid replace- ment. Provide 100% oxy- gen via face mask is anticipat- ed. Upon admis- sion to the emer- gency depart- ment, the nurse should recognize the need to pro- vide 100% oxy- gen via face mask as an essential prescription. The child's SaO2 is be- low the expected reference range and their respira- tory rate is in- creased. Weigh the child is anticipated. The nurse should rec- ognize the need to weigh the child as essential. Chil- dren of the same age weigh differ- 23. The nurse is caring for the child 4 days after admis- sion. Graphic Record 0800: Temperature 38.8° C (101.8° F)Heart rate 124/min- Respiratory rate 22/minBlood pressure 100/56 mm HgSaO2 97% on room airWeight 17.1 kg (37.7 lb)Urine output 15 mL in past hour Nurses' Notes 0800: Child is awake, watching cartoons on television, and parent is at bedside. IV site in right antecubital is with- out redness or edema and dressing is dry and intact. Dressings to left arm and hand, anterior neck, and anterior chest are moderately saturated with serous drainage and several small spots of serosanguineous drainage. Dressings remain intact and smell malodor- ous. Breath sounds are equal and clear bilaterally. Respi- rations are unlabored. Abdomen is soft and nondis- tended. Mucous membranes are moist. Skin turgor is slightly brisk. Pupils are equal, round, and reactive to light and ac- commodation. Child is oriented to place, time, and name. When child attempts to move, they begin to cry. Child reports pain as 8 on the FACES scale. Noted a 1 cm x 2 cm stage 1 pressure injury on the right side of the occiput. Prepared child and parent for transport to hydrother- ent amounts. The amount of fluid resuscitation and medication a pe- diatric patient re- ceives is based on their weight. Dropdown 1: Temperature is correct. When us- ing the urgent vs. nonurgent ap- proach to client care, the nurse should determine that an increased temperature is a priority finding, be- cause it can indi- cate an infection and sepsis. Wound sepsis is most like- ly to occur be- tween the third and fifth day af- ter a burn. There- fore, the nurse should first ad- dress the child's temperature. Dropdown 2: Pain is correct. When using the ur- gent vs. nonurgent approach to client care, the nurse should determine apy and debridement scheduled for 0830. Provider Prescri 24. The nurse is continuing to care for the child. Nurses' Notes 0800: Child is awake, watching cartoons on TV, and parent is at bedside. IV site in right antecubital is without red- ness or edema and dressing is dry and intact. Dress- ings to left arm and hand, anterior neck, and anterior chest are moderately saturated with serous drainage that an 8 out of 10 pain rating on the FACES scale is a priority finding and should be ad- dressed next. Se- vere pain impacts the stress re- sponse, which can lead to complica- tions and adverse- ly affect healing. Change the mor- phine route to fam- ily-controlled anal- gesia via a PCA pump is anticipat- ed. A pain rating of 8 indicates se- vere pain. The use and several small spots of serosanguineous drainage. of a PCA pump Dressings remain intact and smell malodorous. Breath sounds are equal and clear bilaterally. Respi- rations are unlabored. Abdomen is soft and nondis- tended. Mucous membranes are moist. Skin turgor is slightly brisk. Pupils are equal, round, and reactive to light and ac- commodation. Child is oriented to place, time, and name. When child attempts to move, they begin to cry. Child reports pain as 8 on the FACES scale. Noted a 1 cm x 2 cm stage 1 pressure injury on the right side of the occiput. Prepared child and parent for transport to hydrother- apy and debridement scheduled for 0830. 0815: Pediatric Burn Unit Nurses' Notes Provider notified of 0800 assessment and vital signs. should increase the effectiveness of pain manage- ment during move- ment and proce- dures. The nurse should teach the child's primary caregiver about the use of the PCA pump. Obtain a wound culture is antici- pated. The child has an elevated temperature and malodorous green Provider will examine child during hydrotherapy. Mor- phine given for pain rating of 8 on FACES pain rating scale. Child transported via str 25. The nurse is caring for the child 14 days after admis- sion. Graphic Record 0800: wound drainage. The nurse should obtain a wound culture to deter- mine the causative organism and an antibiotic should be administered. Place the child on a pressure-re- duction mattress is anticipated. The child has devel- oped a stage 1 pressure injury on their occiput. A pressure-reduc- tion mattress can help prevent fur- ther tissue injury. Limit daily pro- tein intake is con- traindicated. Chil- dren who have major burns re- quire a high-pro- tein, high-calorie diet to help with wound healing. The nurse should provide high-pro- tein snacks to the child between meals.~ Provide 100% oxy- gen via face mask is correct. The nurse should Temperature 37° C (98.6° F)Heart rate 100/minRespi- ratory rate 20/minBlood pressure 98/56 mm HgSaO2 97% on room airWeight 16.8 kg (37 lb)1300: Temperature 35.8° C (96.4° F)Heart rate 68/minRespi- ratory rate 14/minBlood pressure 90/50 mm HgSaO2 88% on room air Nurses' Notes Pediatric Burn Unit 0800: Reinforced preoperative teaching with the child and parent. Child is awake and alert. Moving all extremities. Child limits their range-of-motion of the left arm. Anterior neck and upper chest dressings are dry and intact. Left arm and hand dressings are intact and slightly moist with serous drainage. Breath sounds are clear and equal bilaterally. Ab- domen is soft and nondistended. Bowel sounds are active in all quadrants. Child remains NPO for surgery. Right antecubital peripherally inserted central catheter (PICC) line dressing is dry and intact. Site is without redness, edema, or drainage. IV maintenance fluids and PCA morphine are infusing through PICC line. Child reports pain as 2 on the FACES pain scale.PACU Nurse 1245: Anterior neck and left chest dressings are dry and intact. Left thigh dressing has a modera provide 100% oxy- gen via face mask to the child be- cause of their SaO2 and respi- ratory rate. The SaO2 should be maintained at 95% or higher and if the SaO2 falls below 95%, supplemen- tal oxygen should be initiated. Check anterior neck and chest dressing for bleed- ing is correct. Upon return from the proce- dure, all surgical dressings should be assessed for drainage and to ensure the dress- ing is intact. Place a warm blanket on the child is correct. The child is ex- hibiting hypother- mia. It is impor- tant for the child to have a stable body temperature because vasocon- striction can dimin- ish blood flow to 26. The nurse is providing discharge teaching to the child and their parent 36 days after admission. Exhibit 1 Nurses' Notes 0900: Home care consultation and supply delivery arrange- ments completed by the child's case manager. 1400: Provided discharge teaching to the parent and child regarding medications, skin and wound care, and psy- chosocial needs. Parent verbalized understanding of teaching. Select 6 statements by the parent that indicate an understanding of the discharge teaching. "I will give my child hydroxyzine to prevent bacterial infection." "I should apply a moisturizer to the scar tissue." "I will use a measured spoon or medicine cup to give my child hydroxyzine." "I can give my child hydroxyzine every 6 hours as needed." "Puppet play can be helpful for my child." "I should avoid giving hydroxyzine at bedtime." the surgical sites and impair heal- ing. Keep the child's head in a neutral position is correct. The child's head should be kept in a neutral alignment to prevent hyper- extension or hy- perflexion and to prevent graft loss. "I should apply a moisturizer to the scar tissue" is cor- rect. Frequent applica- tion of a non-per- fume moisturizer should be applied to the scar tis- sue to help reduce itching the child might experience. "I will use a mea- sured spoon or medicine cup to give my child hy- droxyzine" is cor- rect. All liquid medica- tions should be administered with a measured spoon or cup to pro- "I will avoid massaging the scar tissue." "My child is too young to be concerned about their body image." "I need to assess for any redness or open skin areas before applying my child's left arm splint." "My child will need to use a compression garment to decrease blood supply to the scarred tissue." vide an accurate amount of the pre- scribed dose of medication. "I can give my child hydroxyzine every 6 hours as need- ed" is correct. Hydroxyzine is ad- ministered every 6 to 8 hr each day as needed. "Puppet play can be helpful for my child" is correct. Preschoolers en- gage in imagina- tive play. The use of puppets will en- courage the child to express their feelings through imaginary play. "I need to assess for any redness or open skin ar- eas before apply- ing my child's left arm splint" is cor- rect. It is impor- tant that the child's skin be assessed for redness, open areas, or blisters prior to putting on a splint. The splint is used to pre- vent contractures of the extremities and promote nor- mal alignment dur- ing the healing process. Because the splint might be worn for a long period of time, the child's growth might cause the splint to not fit properly and can cause a pressure injury. "My child will need to use a compression gar- ment to decrease blood supply to the scarred tissue" is correct. Using a compres- sion garment on the scar tissue de- creases the blood supply to avoid nourishing the hy- pertrophic tissue. It also forces the collagen into a more normal align- ment. Compres- sion garments are worn during the healing of the burned tissue and 27. A nurse is caring for a toddler who has spastic (pyra- midal) cerebral palsy. Which of the following findings should the nurse expect? (Select all that apply.) Negative Babinski reflex Ankle clonus Exaggerated stretch reflexes Uncontrollable movements of the face Contractures 28. 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 should be worn as much as possible. Ankle clonus is correct. The nurse should expect a child who has spastic cerebral palsy to exhibit an- kle clonus, which is a rhythmic re- flex tremor when the foot is dorsi- flexed Exaggerated stretch reflexes is correct. The nurse should expect a child who has spastic cerebral palsy to exhibit spasticity or exaggerated stretch reflexes. . Contractures is correct. The nurse should expect a child who has spastic cerebral palsy to exhibit contractures due to the tightening of the muscles. "Let's talk about some of the ways you have handled previous stressors following statements should the nurse make? "It is important that you provide emotional support for your family at this time." "You have to do what you feel is best. Everything will turn out fine." "I know how you feel. This is an extremely stressful time for your family." "Let's talk about some of the ways you have handled previous stressors in your life." 29. A nurse in an emergency department is caring for a toddler who has partial-thickness burns on their right arm. Which of the following actions should the nurse take? Insert a nasogastric tube. Initiate prophylactic antibiotic therapy. Cleanse the affected area with mild soap and water. Apply a topical corticosteroid to the affected area. 30. A nurse is assessing a 3-year-old toddler at a well-child visit. Which of the following manifestations should the nurse report to the provider? Blood pressure 90/50 mm Hg Respiratory rate 45/min Weight 14.5 kg (32 lb) Heart rate 110/min in your life." This statement of- fers a general lead to allow the parent to express their feelings and previ- ous actions when faced with stress- ful situations. It also helps the par- ent to focus on ways that they can cope with the cur- rent situation. Cleanse the affect- ed area with mild soap and water. The nurse should wash the affect- ed area with mild soap and water to remove any loose tissue that could cause infection. Respiratory rate 45/min The nurse should identify that a res- piratory rate of 45/min is above the expected ref- erence range of 20 to 25/min for a 3-year-old tod- dler and can in- dicate respirato- 31. A nurse is caring for a school-age child who is re- ceiving chemotherapy and is severely immunocom- promised. Which of the following actions should the nurse take? Use surgical asepsis when providing routine care for the child. Administer the measles, mumps, and rubella (MMR) vaccine to the child. Screen the child's visitors for indications of infection. Infuse packed RBCs. 32. A nurse is receiving change-of-shift report for four children. Which of the following children should the nurse see first? A school-age child who has sickle cell anemia and reports decreased vision in the left eye A school-age child who has cystic fibrosis and a fre- quent nonproductive cough A preschooler who has asthma and a peak flow meter reading in the green zone An adolescent who has meningitis and reports a sen- sitivity to lights and noise ry dysfunction and acute respirato- ry distress. There- fore, the nurse should report this finding to the provider Screen the child's visitors for indica- tions of infection. A child who is severely immuno- compromised is unable to ade- quately respond to infectious organ- isms, resulting in the potential for overwhelming in- fection. Therefore, the nurse should screen the child's visitors for indica- tions of infection. A school-age child who has sickle cell anemia and reports decreased vision in the left eye When using the ur- gent vs. nonurgent approach to client care, the nurse should determine the priority find- ing is a report 33. A nurse is assessing a toddler who has gastroenteri- tis and is exhibiting manifestations of dehydration. Which of the following findings is the nurse's priority? Skin breakdown Hypotension Hyperpyrexia Tachypnea 34. 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? Administer ibuprofen to the child for a temperature greater than 38º C (100.4º F). of decreased vi- sion in the left eye. This finding indi- cates that the child is experiencing a vaso-occlusive cri- sis and should be reported to the provider imme- diately. Therefore, the nurse should see this child first. Tachypnea When using the airway, breath- ing, and circu- lation approach to client care, the nurse's priority finding is the tod- dler's tachypnea. Tachypnea is a re- sult of the kid- neys being un- able to excrete hy- drogen ions and produce bicarbon- ate, which leads to metabolic acido- sis. Initiate seizure precautions for the child. A sodium level of 129 mEq/L indi- cates hyponatrem- Assess the child's blood pressure every 8 hr. Weigh the child weekly at various times of the day. Initiate seizure precautions for the child. 35. Provider Prescriptions Tuberculin skin test (TST)Measles, mumps, and rubella (MMR) vaccineIn- activated influenza vaccineDiphtheria, tetanus, and pertussis (DTaP) vaccine Graphic RecordRespiratory rate 24/minHeart rate 115/minTemperature 36.9° C (98.4° F) ia and places the child at increased risk for neurolog- ical deficits and seizure activity. The nurse should complete a neu- rologic assess- ment and imple- ment seizure pre- cautions to main- tain the child's safety. Withhold the measles, mumps, and rubella (MMR) vaccine. The nurse should recognize that an allergy to History and Physical Age 15 monthsHeight 71.1 cm (2n8eomycin with an in)Allergies Neomycin (anaphylactic reaction)Care- giver reports rhinitis with clear nasal drainage for 2 daysOccasional nonproductive cough for 2 daysHis- tory of asthma A nurse in a provider's office is preparing to adminis- anaphylactic reac- tion is a contraindi- cation for receiv- ing the MMR vac- cine. Clients who ter immunizations to a toddler during a well-child visit. have a severe al- Which of the following actions should the nurse plan to take? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) Withhold the measles, mumps, and rubella (MMR) vac- cine. Withhold the diphtheria, tetanus, and pertussis (DTaP) vaccine. Withhold the influenza vaccine. Withhold the tuberculin skin test (TST). lergy to eggs or gelatin should not receive this vac- cine. 36. A nurse is teaching the parent of an infant who has a Pavlik harness for the treatment of developmental dysplasia of the hip. The nurse should identify that which of the following statements by the parent indi- cates an understanding of the teaching? "I should remove the harness at night to allow my infant to stretch her legs." "I will need to adjust the straps on the harness once each week." "I should apply baby powder to my infant's skin twice daily." "I will place my infant's diapers under the harness straps." 37. A nurse is planning care for a toddler who has a serum lead level of 4 mcg/dL. Which of the following actions should the nurse plan to take? Instruct the parents to decrease the calcium in their toddler's diet. Prepare the toddler for chelation therapy. Refer the family to Child Protective Services. Schedule the toddler for a yearly rescreening. 38. A nurse on a pediatric unit is caring for a school-age child. Nurses' Notes 0830:Child is alert and responsive to stimuli. Skin is "I will place my in- fant's diapers un- der the harness straps." To prevent soil- ing of the harness, the parent should apply the infant's diaper under the straps. Schedule the tod- dler for a yearly re- screening. The nurse should schedule the tod- dler for a lead lev- el rescreening in 1 year and educate the family on ways to prevent expo- sure. Arterial blood gas- es is correct. The child's ar- terial blood gas- warm and dry. Capillary refill less than 3 seconds. Res- es (ABGs) indicate pirations regular and shallow. Mild intercostal retrac- tions noted. Expiratory wheezes auscultated in the an- respiratory alkalo- sis, which is asso- terior and posterior lung bases. Abdomen is soft, flat, ciated with compli- and non-distended.1100:Child appears restless. Mod- erate intercostal retractions noted. Scattered rhonchi anterior bases with wheezing noted on inhalation and exhalation. Point of maximum intensity (PMI) in the left cations of asthma, such as hyperven- tilation and hypox- ia. Therefore, the mid-clavicular line 4th intercostal space. Heart rate is nurse should re- regular without murmurs, gallops, or rubs. Radial and pedal pulse 2+ bilaterally. Vital Signs 0830: Temperature 37.1° C (98.8° F)Heart rate 100/minRespi- ratory rate 22/minBlood pressure 90/60 mm HgPulse oximetry 97% on 2 L of oxygen via nasal cannula1100: Temperature 37.1° C (98.8° F)Heart rate 110/minRespi- ratory rate 30/minPulse oximetry 94% on 2 L of oxygen via nasal cannula Diagnostic Results 1200:CBC:Hemoglobin 10 g/dL (10 to 15.5 g/dL)Hema- port these findings to the provider. WBC count is cor- rect. The child's WBC count is above the ex- pected reference range, which could be an indication of infection or inflam- mation. Therefore, tocrit 32% (32% to 44%)WBC count 11,000/mm3 (5,000 the nurse should to 10,000/mm3)Arterial Blood Gases (ABGs):pH 7.49 (7.35 to 7.45)PCO2 32 mm Hg (35 to 4 report this finding to the provider. Oxygen saturation level is correct. The child's oxy- gen saturation lev- el has decreased below the ex- pected reference range despite the use of supplemen- tal oxygen. There- fore, the nurse should report this finding to the provider. Respiratory as- sessment is cor- rect. The child's respiratory as- sessment indi- cates increased respiratory dis- tress, as evi- 39. A nurse is caring for a 15-year-old client who is mar- ried 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? "You can sign the consent form because you are mar- ried." "Your spouse should sign the consent form for you." "Your parent should sign the consent form for you." "You can appoint a legal guardian to sign the consent form." 40. A nurse is teaching a school-age child who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the child indicates an understanding of the teaching? "I will puncture the pad of my finger when I am testing my blood glucose." "I will give myself a shot of regular insulin 30 minutes before I eat breakfast." "I will eat a snack of 5 grams of carbohydrates if my blood glucose is low." denced by the presence of tachypnea, retrac- tions, and in- creased wheez- ing. Therefore, the nurse should re- port these findings to the provider. "You can sign the consent form be- cause you are married." The nurse should inform the ado- lescent that mar- riage gives ado- lescents the legal right to consent to surgical pro- cedures and sign other legal doc- uments that they would not other- wise be able to sign due to their age. "I will give myself a shot of regular insulin 30 minutes before I eat break- fast." The child should administer regular insulin 30 min be- fore meals so that the onset coin- "I will decrease the amount of fluids I drink when I am sick." 41. A charge nurse in an emergency department is preparing an in-service for a group of newly licensed nurses about the manifestations of child maltreat- ment. Which of the following manifestations should the charge nurse include as a potential indication of physical abuse? Recurrent urinary tract infections Symmetric burns of the lower extremities Failure to thrive Lack of subcutaneous fat 42. A nurse is caring for a preschooler who has been receiving IV fluids via a peripheral IV catheter. When preparing to discontinue the IV fluids and catheter, which of the following actions should the nurse plan to take? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.) cides with food in- take. Symmetric burns of the lower ex- tremities The nurse should include that sym- metric burns to the lower extremities can indicate physi- cal abuse. The pat- terns are usual- ly characteristic of the method or ob- ject used, such as cigar or cigarette burns, or burns in the shape of an iron. First, the nurse should turn off the IV pump. Next, the nurse should occlude the IV tubing, and then remove the tape securing the catheter. Last, the nurse should apply pres- sure over the catheter insertion site. 43. A nurse is preparing to administer an immunization to a 4-year-old child. Which of the following actions should the nurse plan to take? Place the child in a prone position for the immuniza- tion. Request that the child's caregiver leave the room dur- ing the immunization. Administer the immunization using a 24-gauge nee- dle. Inject the immunization slowly after aspirating for 3 seconds. 44. A nurse is providing teaching to the parent of an infant who has diaper dermatitis. The nurse should instruct the parent to apply which of the following to the af- fected area? Zinc oxide Antibiotic ointment Talcum powder Antiseptic solution 45. A nurse is assessing a 4-year-old child at a well-child visit. Which of the following developmental mile- stones should the nurse expect to observe? Identifies right from left hand Uses a utensil to spread butter Cuts an outlined shape using scissors Draws a stick figure with seven body parts Administer the im- munization using a 24-gauge needle. The nurse should administer an im- munization for a 4-year-old child using a 22- to 25- gauge nee- dle to minimize the amount of pain the child experiences. Zinc oxide Diaper dermatitis is a common in- flammatory skin disorder caused by contact with an irritant such as urine, feces, soap, or friction, and takes the form of scaling, blisters, or papules with ery- thema. Providing a protective barrier, such as zinc ox- ide, against the ir- ritants allows the skin to heal. Cuts an outlined shape using scis- sors The nurse should recognize that an expected develop- mental milestone 46. A nurse is caring for a school-age child who is re- ceiving a blood transfusion. Which of the following manifestations should alert the nurse to a possible hemolytic transfusion reaction? Laryngeal edema Flank pain Distended neck veins Muscular weakness 47. A nurse is providing discharge teaching to the parent of a child who is 1 week postoperative following a cleft palate repair. For which of the following members of the interprofessional team should the nurse initiate a referral? Occupational therapist Speech therapist Respiratory therapist Physical therapist 48. A nurse on a pediatric unit is admitting a preschooler. Vital Signs 0715: Temperature 38.3° C (100.9° F)Heart rate 126/minRes- piratory rate 26/minPulse oximeter 97% of a 4-year-old child is using scis- sors to cut out a shape. Flank pain The nurse should recognize that flank pain is caused by the breakdown of RBCs and is an in- dication of a he- molytic reaction to the blood transfu- sion. Speech therapist The nurse should initiate a referral for a speech ther- apist for a child who is postoper- ative following a cleft palate repair. A child who has a cleft palate will re- quire speech ther- apy immediately following the repair to support speech development and future articulation. Dropdown 1: Splenomegaly is correct. The child's positive mononu- cleosis rapid test Physical Examination 0715:Guardians report that the child has been tired lately and has been experiencing a sore throat and fever. Child is tolerating sips of liquids, but is re- fusing solid foods. Guardians report that the child is voiding dark yellow urine.0730:Child is alert and responsive to verbal stimuli. Mucous membranes are dry and sticky. Skin turgor without tenting. Tonsils enlarged and erythematous. Respirations are regular and non-labored. No accessory muscle use noted. Lungs clear anterior and posterior bilaterally. Point of maximum intensity (PMI) in the left mid-clavicular line 4th intercostal space. Heart rate is regular without murmurs, gallops, or rubs. Radial and pedal pulse 2+ bilaterally. Capillary refill greater than 2 seconds. Ab- domen flat and non-distended. Bowel sounds active in all four quadrants. Extremities are warm and dry to touch. Diagnostic Results 0900: Mononucleosis rapid test: positive (negative) result indicates the presence of in- fectious mononu- cleosis, a condi- tion caused by the Epstein-Barr virus. Therefore, the nurse should iden- tify that the child is at risk for develop- ing splenomegaly, a common compli- cation of infectious mononucleosis. Dropdown 2: Positive mononu- cleosis rapid test is correct. The child's positive mononu- cleosis rapid test result indicates the After reviewing the information in the medical record, presence of in- the nurse should identify that the child i 49. A nurse in an emergency department is caring for a school-age child who has appendicitis and rates their abdominal pain as 7 on a scale of 0 to 10. Which of the fectious mononu- cleosis, a condi- tion caused by the Epstein-Barr virus. Therefore, the nurse should iden- tify that the child is at risk for develop- ing splenomegaly, a common compli- cation of infectious mononucleosis. Give morphine 0.05 mg/kg IV. A pain level of 7 following actions should the nurse take? Instill a 500 mL tap water enema. Give morphine 0.05 mg/kg IV. Administer polyethylene glycol 1g/kg PO. Apply a heating pad to the child's abdomen. 50. A nurse is caring for a school-age child who is in Buck's traction following a leg fracture 24 hr ago. Which of the following actions should the nurse take? Change the child's position every 2 hr. Clean the peripheral pin sites with chlorhexidine so- lution every 4 days. Assess peripheral pulses once every 4 hr. Ensure that the head of the bed is elevated to a 90° angle. 51. A nurse is caring for a school-age child who has expe- rienced a tonic-clonic seizure. Which of the following actions should the nurse take during the immediate postictal period? Place the child in a side-lying position. on a scale of 0 to 10 is considered severe. The nurse should administer an analgesic med- ication for pain re- lief. Assess peripheral pulses once every 4 hr. Buck's traction is a type of skin trac- tion that can be used to immobi- lize extremities pri- or to surgery. The nurse should pro- vide frequent neu- rovascular checks at least every 4 hr after the first 24 hr of placement in Buck's traction. The nurse should monitor and re- port signs of neu- rovascular impair- ment in the ex- tremities such as cyanosis, edema, pain, absent puls- es, and tingling. Place the child in a side-lying position. The nurse should place the child in a side-lying position Delay documentation until the child is fully alert. Give the child a high-carbohydrate snack. Administer an oral sedative to the child. 52. A nurse is auscultating the lungs of an adolescent who has asthma. The nurse should identify the sound as which of the following? (Click on the audio button to listen to the clip.) Biot respiration Cheyne-Stokes respiration Tachypnea Bradypnea 53. A nurse is creating a plan of care for an infant who has an epidural hematoma from a head injury. Which of the following interventions should the nurse include in the plan? Position the infant side-lying with their head at a 0° to 5° angle. Perform a neurological assessment every 4 hr. Suction the infant's nares to remove secretions. Implement seizure precautions for the infant. 54. A nurse is teaching the guardian of a 6-month-old infant about car seat use. Which of the following state- ments by the guardian indicates an understanding of the teaching? "I should secure the car seat using lower anchors and to prevent aspira- tion. Tachypnea The nurse should identify the sound heard during auscultation as tachypnea, which is a rapid, regu- lar breathing pat- tern. This breath- ing pattern often occurs with anxi- ety, fever, metabol- ic acidosis, or se- vere anemia. Implement seizure precautions for the infant. An infant who has an epidur- al hematoma is at great risk for seizure activ- ity. Therefore, the nurse should im- plement seizure precautions for the child. "I should secure the car seat using lower anchors and tethers instead of the seat belt." tethers instead of the seat belt." "I should position the car seat harness 1 inch above my baby's shoulders." "I will make sure that the car seat is placed at a 90-de- gree angle." "I will pad my baby's car seat with a blanket for trav- eling long distances." 55. A nurse is caring for an infant who has respiratory syncytial virus (RSV). Which of the following actions should the nurse implement for infection control? Have a designated stethoscope in the infant's room. Place the infant in a room equipped with negative airflow. Administer palivizumab as prescribed for the infant. Remove gloves after leaving the infant's room. 56. 56. Lower anchors and tethers, or the LATCH child safe- ty seat system, should be used to secure an infant's car seat in the ve- hicle. This system provides anchors between the front cushion and the back rest for the car seat. There- fore, if this system is available, the seat belt does not have to be used Have a designated stethoscope in the infant's room. The nurse should initiate droplet pre- cautions for an in- fant who has RSV because the virus is spread by di- rect contact with respiratory secre- tions. Therefore, designated equip- ment, such as a blood pressure cuff and a stetho- scope, should be placed in the in- fant's room. A nurse is assessing the vital signs of a 10-year-old child following a burn injury. The nurse should identify that which of the following findings is an indication of early septic shock? Blood pressure 130/90 mm Hg Heart rate 60/min Temperature 39.1° C (102.4° F) Urinary output 100 mL/hr 57. A nurse is assessing a school-age child who has meningitis. Which of the following findings is the pri- ority for the nurse to report to the provider? Reports a headache as 6 on a 0 to 10 pain scale Petechiae on the lower extremities Nuchal rigidity Positive Kernig's sign 58. A school nurse is assessing an adolescent who has multiple burns in various stages of healing. Which of the following behaviors should the nurse identify as a Temperature 39.1° C (102.4° F) The nurse should identify that a tem- perature of 39.1° C (102.4° F) is above the expected refer- ence range of 37° to 37.5° C (98.6° to 99.5° F) for a 10-year-old child. The nurse should expect a child who has early septic shock to have a fever and chills. Petechiae on the lower extremities The presence of a petechial or purpuric rash on a child who is ill can indi- cate the presence of meningococ- cemia. This type of rash indicates the greatest risk of se- rious rapid compli- cations from sep- sis and should be reported im- mediately to the provider. Denies discom- fort during assess- ment of injuries possible indication of physical abuse? Expresses a reluctance to leave home Provides a detailed description of how the burns oc- curred Denies discomfort during assessment of injuries Describes strong relationships with peers 59. A nurse is caring for a toddler who is experiencing acute diarrhea and has moderate dehydration. Which of the following nutritional items should the nurse offer to the toddler? Apple juice Peanut butter Chicken broth Oral rehydration solution 60. A nurse is providing teaching about play activities for social development to the parents of a preschooler. Which of the following play activities should the nurse recommend for the child? Playing pat-a-cake Using a push-pull toy Creating a scrapbook Playing dress-up The nurse should suspect child mal- treatment in the form of physi- cal abuse if the adolescent has a blunted response to painful stimuli or injury. Oral rehydration solution A toddler who has acute diar- rhea should con- sume an oral re- hydration solution to replace elec- trolytes and wa- ter by promoting the reabsorption of water and sodium. This promotes re- covery from dehy- dration. Playing dress-up The nurse should instruct the par- ents that at the preschool age, play should focus on social, men- tal, and physi- cal development. Therefore, playing dress-up is a rec- ommended play activity for this chil