19 kiddos in Action
A nurse is caring for a preschooler who is scheduled for hydrotherapy treatment for wound debridement following a burn injury. Which of the following actions should the nurse take prior to the procedure?
Administer an analgesic to the child.
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 give myself a shot of regular insulin 30 minutes before I eat breakfast."
A nurse is assessing an infant who has a ventricular septal defect. Which of the following findings should the nurse expect?
Loud, harsh murmur
A nurse is caring for a school-age child who has experienced 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.
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
A hospice nurse is caring for a preschooler who has a terminal illness. The father tells the nurse that he cannot cope anymore and has decided to move out of the house. Which of the following statements should the nurse make?
"Let's talk about some of the ways you have handled previous stressors in your life."
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?
Administer the immunization using a 24-gauge needle.
The 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 received tobramycin during a hospitalization 2 weeks ago.
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 affected area?
Zinc oxide
adolescent who has asthma
tachypnea
A school nurse is assessing an adolescent who has scoliosis. Which of the following findings should the nurse expect?
unilateral rib hump
A nurse is teaching the parent of an infant about ways to prevent sudden infant death syndrome (SIDS). Which of the following instructions should the nurse include?
"Give the infant a pacifier at bedtime."
A nurse in the emergency department is caring for a toddler who has a partial thickness burns on their right arm. Which of the following actions should the nurse take?
Cleanse the affected area with mild soap and water.
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?
Petechiae on the lower extremities
A nurse is caring for a school-age child who is receiving chemotherapy and is severely immunocompromised. Which of the following actions should the nurse take?
Screen the child's visitors for indications of infection.
A charge nurse in an emergency department is preparing an in-service for a group of newly licensed nurses on the clinical manifestations of child maltreatment. Which of the following manifestations should the charge nurse include as suggestive of potential physical abuse?
Symmetric burns of the lower extremities
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 indicates an understanding of the teaching?
"I will place my infant's diapers under the harness straps."
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."
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 after you eat."
A nurse is caring for a toddler who has spastic (pyramidal) cerebral palsy. Which of the following findings should the nurse expect? (Select all that apply.)
-Ankle clonus -Exaggerated stretch reflexes -Contractures
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 laboratory values indicates effectiveness of the current treatment?
Sodium 140 mEq/L
The 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 inter professional team should the nurse initiate a referral?
Speech therapist
A nurse is assessing a toddler who has gastroenteritis and is exhibiting manifestations of dehydration. Which of the following findings is the nurses priority?
tachypnea
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%
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?
Oral rehydration solution
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?
"I should keep my child indoors when I mow the yard."
A nurse is teaching the parents of a school-age child who has a new diagnosis of osteomyelitis of the tibia. The nurse should identify that which of the following statements by the parents indicates an understanding of the teaching?
"My child will receive antibiotics for several weeks."
A school nurse is preparing to administer atomoxetine 1.2 mg/kg/day PO to a school aged child who weights 75 lbs. Available is atomoxetine 40 mg/capsule. How many capsules should the nurse administer per day?
1
McBurney's point
A
A nurse is receiving change-of-shift report on 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.
The nurse is assessing a school-age child who has peritonitis. Which of the following findings should the nurse expect?
Abdominal distention
A nurse is assessing a school-age child immediately following a perforated appendix repair. Which of the following findings should the nurse expect?
Absence of peristalsis
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?
Administer epinephrine IM to the child.
A nurse is preparing an adolescent for a lumbar puncture. Which of the following actions should the nurse take?
Apply topical analgesic cream to the site 1 hr prior to the procedure.
A nurse is caring for a school-age child who in in Buck's traction following a leg fracture 24 hr ago. Which of the following actions should the nurse take?
Assess peripheral pulses once every 4 hr.
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?
Cuts an outlined shape using scissors.
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 possible indication of physical abuse?
Denies discomfort during assessment of injuries.
A nurse in an urgent care clinic is assessing an adolescent who has an upper respiratory tract infection. Which of the following findings should the nurse identify as a manifestation of pertussis?
Dry, hacking cough
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?
Epinephrine
A nurse is reviewing the laboratory report of a 7 year-old child who is receiving chemotherapy. Which of the following lab values should the nurse report to the provider?
Hgb 8.5 g/dL
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?
Implement seizure precautions for the infant.
A nurse is admitting a school-age child who has Pertussis. Which of the following actions should the nurse take?
Initiate droplet precautions for the child.
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?
Initiate seizure precautions for the child.
A nurse is caring for a 15 year-old client following a head injury. Which of the following findings should the nurse identify as an indication that the child is developing syndrome of inappropriate antidiuretic hormone secretion (SIADH)?
Mental confusion
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?
Respiratory rate 45/min
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?
Serum creatinine 3.0 mg/dL
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 in an indication of early septic shock?
Temperature 39.1° C (102.4° F)
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?
You can sign the consent form bc you are married
A nurse is proving 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?
White rice
A nurse in a provider's office if preparing to administer immunizations to a toddler during a well-child visit. Which of the following actions should the nurse plan to take?
Withhold the measles, mumps, and rubella (MMR) vaccine.
A nurse is teaching the guardian of a 6-month-old infant about car seat use. Which of the following statements by the guardian indicates an understanding of the teaching?
"I should secure the car seat using lower anchors and tethers instead of the seat belt."
A nurse is reviewing the lumbar puncture results of a school-age child suspected of having bacterial meningitis. Which of the following results should the nurse identify as a finding associated with bacterial meningitis?
Increased protein concentration
A nurse is providing teaching about social development to the parents of a preschooler. Which of the following play activities should the nurse recommend for the child?
Playing dress up
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?
Schedule the toddler for a yearly rescreening.
A nurse in an emergency department is performing an admission assessment on a 2 week-old male newborn. Which of the following findings is the priority for the nurse to report to the provider?
substernal retractions
The 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?
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 pressure over the catheter insertion site.
A nurse is caring for a school-age child who is receiving a blood transfusion. Which of the following manifestations should alert the nurse to a possible hemolytic transfusion reaction?
Flank pain
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 following actions should the nurse take?
Give morphine 0.05mg/kg IV
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.
A nurse is preparing to collect a sample from a toddler for a sickle-turbidity test. Which of the following actions should the nurse plan to take?
perform a finger stick