ATI FINAL
A nurse is caring for a toddler who's parent states that the child has a mass in his abdominal area and his urine is a pink color. Which of the following actions is the nurse's priority? A. Schedule the child for an abdominal ultrasound B. Instruct the parent to avoid pressing on the abdominal area C. Determine if the child is having pain D. Obtain a urine specimen for a urinalysis
B. Instruct the parent to avoid pressing on the abdominal area
A nurse is providing discharge teaching to the parents of a three-month-old infant following a cheiloplasty. which of the following instructions should the nurse include? A- Clean your baby's sutures daily with a mixture of chlorhexidine and water B- expect your baby to swallow more than usual over the next few days C- inspect your baby's tongue for white patches using a tongue depressor every 8 hours D- apply a thin layer of antibiotic ointment on your babies' suture line daily forthe next three days
D- apply a thin layer of antibiotic ointment on your babies' suture line daily for the next three days.
The nurse is providing anticipatory guidance to the mother of a toddler. Which of the following expected Behavior characteristics of toddlers should the nurse include in the teaching? A- Controls impulsive feelings B- understand right from wrong C- usually separated from parents for long periods of time D- expresses likes and dislikes.
D- expresses likes and dislikes. The nurse should teach the mother that her toddler will begin to express her likes and dislikes. This is the time in life when a toddler is developing autonomy and self-concept. She will try to assert herself and frequently refuse to comply. The parent should allow the child to have some control but also set limits in order for her to learn from her behavior and learn to control her actions.
A nurse is collecting data from an adolescent. Which of the following represents the greatest risk for suicide? A. Availability of firearms B. Family conflict C. Homosexuality D. Active psychiatric disorder
D. Active psychiatric disorder
A nurse is collecting data from a child who has spina bifida occulta. Which of the following findings should the nurse expect? A. Hip dislocation B. Flaccid paralysis of lower extremities C. Hydrocephalus D. Dimple in sacral area
D. Dimple in sacral area
A nurse is providing teaching to an adolescent about how to manage tinea pedis. Which of the following statements by the Adolescent indicates an understanding of the teaching? A- I should buy some plastic shoes to wear at the swimming pool B- I should wear sandals as much as possible C- I should place the permethrin cream between my toes twice daily D- I should seal my nonwashable shoes in plastic bags for a couple of weeks
.....
A nurse is caring for a school-age child who has peripheral edema. Which of the following assessments should the nurse perform to confirm peripheral edema?A- Palpate the dorsum of the child's feet B- play the child daily using the same scale C- assess the child's skin turgor D- observe the child for periorbital swelling
A- Palpate the dorsum of the child's feet The nurse should palpate the dorsum of the feet by pressing her fingertip against a bony prominence for 5 seconds to assess for peripheral edema.
A nurse is caring for a school-age child who has primary nephrotic syndrome and is taking prednisone. Following one week of treatment, which of the following clinical manifestationsindicate to the nurse that the medication is effective? A- Decrease edema B- increased abdominal girth C- decreased appetite D- increased protein in the urine
A- Decrease edema
A nurse is an urgent care clinic is assisting with the care of a toddler who ingested 30 tablets of aspirin. Which of the following substances should the nurse administer to the toddler? A. Activated charcoal. B. Acetylcysteine (antidote for acetaminophen) C. A chelating agent (usually used for iron) D. Digoxin immune FAB
A. Activated charcoal.
A nurse is collecting data from an infant who has hypertrophic pyloric stenosis. Which of the following findings should the nurse expect? A. Projectile vomiting B. Bile colored vomit C. Absentbowelsounds D. Fever
A. Projectile vomiting
A nurse is providing teaching to the parents of a preschooler who has heart failure and who is to begin taking Digoxin twice daily. Which of the following instructions should the nurse include in the teaching? A- Use a kitchen teaspoon to measure the medication B- brush the child's teeth after giving the medication C- double the next dose If the child misses a dose D- repeat the dose If the child vomits
B- brush the child's teeth after giving the medication. The nurse should instruct the parents to brush the child's teeth after administering digoxin to prevent tooth decay caused by the medication, which comes as a sweetened liquid to enhance the taste.
A nurse in the emergency department is caring for a school-age child who has epiglottitis.Which of the following actions should the nurse take? A- Obtain a throat culture from the child B- monitor the child's oxygen saturation C- put a warm mist humidifier in the child's room D- Place the child in a Supine position
B- monitor the child's oxygen saturation.
A nurse is collecting data from an infant. Which of the following sites is the most reliable location to check the infant's pulse? A. Carotid B. Apical C. Dorsalis pedis D. Temporal
B. Apical
A nurse is caring for a school age child who has mild persistent asthma. Which of the following findings should the nurse expect? (select all the apply) A. Symptoms are continual throughout the day B. Daytime symtoms occur more than twice per week C. Nighttime symptoms occur approximately twice per month D. Minor limitations occur with normal activity E. Peak expiratory flow (PEF) is greater than or equal to 80% of the predicted value
B. Daytime symptoms occur more than twice per week. D. Minor limitations occur with normal activity E. Peak expiratory flow (PEF) is greater than or equal to 80% of the predicted value
A nurse is caring for a 3-year-old client who has persistent otitis media. To help identify contributing factors, the nurse should ask the parents which of the following questions? A. Has your daughter been drinking 6 glasses of water a day? B. Does anyone smoke in the same house as your daughter? C. Does your daughter get water in her ears when you bathe her? D. Has your daughter had a lot of earwax in her ears over the last month?
B. Does anyone smoke in the same house as your daughter?
A nurse is caring for an infant who has spina bifida. Which of the following actions should the nurse take? A. Feed the infant through an BG tube B. Place the infant in prone position C. Cover the infants lesion with a dry cloth (cover infant with moist sterile cloth) D. Perform range of motion exercises to the infant's hips
B. Place the infant in prone position.
A nurse is caring for a child who has atopic dermatitis. Which of the following findings should the nurse expect? A. Nonpruritic erythematous papules B. Rash with thick skin C. Maculopapular lesions between fingers and toes D. Inflamed area with white exudate
B. Rash with thick skin
A nurse is caring for an infant who has gastroesophageal reflux. The nurse should place the infant in which of the following positions after feeding? A. Prone (fundamentals) B. Upright(ATI) C. Leftside D. Right side
B. Upright(ATI)
A nurse is planning care for a child who has epiglottitis. Which of the following actions should the nurse plan to take? A. Obtain a throat culture B. prepare the child for a neck radiograph C. initiate airborne precaution (droplet) D. visualize the epiglottitis using a tongue depressor (it can stimulate spasm and cause airway obstruction)
B. prepare the child for a neck radiograph
A nurse in an Emergency Department is assessing a three-month-old infant who has rotavirusand is experiencing acute vomiting and diarrhea. Which of the following manifestations should the nurse identify as an indication that the infant has moderate to severe dehydration? A- Heart rate 124/ minute B- increase tear production C- sunken anterior fontanel D- capillary refill 2 seconds
C- sunken anterior fontanel
A nurse is assessing the vital signs of a 10-year-old child following a burn injury. Which of the following clinical manifestations indicate early septic shock? A- Blood pressure 130/ 90 B- heart rate 60/ Minute C- temperature 39.1 degrees Celsius or 102.4 degrees Fahrenheit D- urinary output 100 mL/hr
C- temperature 39.1 degrees Celsius or 102.4 degrees Fahrenheit
A nurse is preparing to administer ibuprofen 5 mg per kg every 6 hours PRN for temperatures above 38.0 degrees Celsius or 100.5 degrees Fahrenheit to an infant who weighs 17.6 lb. The infant has a temperature of 38.4 degrees Celsius or 100 + 1.2 degrees Fahrenheit. Available is ibuprofen liquid 100mg/ 5 ml. how many milliliters should the nurse administer to the infant per dose? Round the answer to the nearest whole number. Use a leading zero if it applies.
2 mL
A nurse in the emergency department is caring for an adolescent who has severe abdominal pain due to appendicitis. Which of the following locationsshould the nurse identify as mcburney's point?
A is correct. The nurse should identify the lower right quadrant of the abdomen between the umbilicus and the anterior iliac crest as the location of Burney's point.
A nurse is receiving change-of-shift Report on for children. Which of the following children should the nurse assesses first? A- A toddler who has a concussion and an episode of forceful vomiting B- an adolescent who has infective endocarditis and reports having a headache C- an adolescent who was placed into Halo traction 1 hour ago and rates his pain at a 6 on a 0-10 scale D- school-age child who has acute glomerulonephritis and brown colored urine
A- A toddler who has a concussion and an episode of forceful vomiting. When using the urgent vs. no urgent approach to client care, the nurse should assess this child first. An episode of forceful vomiting is an indication of increased intracranial pressure in a toddler who has a concussion.
A nurse is creating a plan of care for a preschooler who has Wilms tumor and is scheduled for surgery. Which of the following interventions should the nurse include? A- Avoid palpating the abdomen when bathing the child before surgery B- refrain from auscultating the child bowel sounds during the postoperative assessment C- encourage the child to play with other children on the unit prior to surgery D- explain to the child that his pain will be managed after the surgery
A- Avoid palpating the abdomen when bathing the child before surgery.
A nurse is reinforcing teaching with the mother of an infant who has oral candidiasis and is breastfeeding which of the following instructions should the nurse include in the teaching? A. Wash hands prior to each breastfeeding. B. Swab the infants mouth with salt water twice daily C. Change to formula feeding with a bottle D. Hand wash pacifier in warm soapy water each day
A. Wash hands prior to each breastfeeding
Teaching the parents of a school-aged child who has a new diagnosis of osteomyelitis of the tibia. The nurse should identify that which of the followingstatements by the parents indicates an understanding of the teaching? A. m=my child will have a cast until healing is complete B. My child will receive antibiotics for several weeks. C. My child can return to playing sports once he is discharged. D.My child needs to be in contact isolation.
B. My child will receive antibiotics for several weeks. The nurse should instruct the parent that the child will receive antibiotic therapy for at least 4weeks. Surgery might be indicated if the antibiotics are not successful.
A nurse is reinforcing teaching with a parent of an 8-year-old child who has a fracture of the epiphyseal plate. Which of the following statements should the nurse include in the teaching? A. Fractures in a child take longer to heal than fractures in an adult B. Normal bone growth can be affected by the fracture C. Bone marrow can be lost through the fracture D. Your child will need to increase his calcium intake to 3,000 milligrams daily
B. Normal bone growth can be affected by the fracture
A nurse is caring for a 4-year-old child who has dehydration. Which of the following findings should the nurse identify as the priority? A. Blood glucose 110 mg/dL B. Potassium 2.5 mEq/L C. Sodium142mEq/L D. Urine specific gravity 1.025
B. Potassium 2.5 mEq/L
A nurse is caring for a child who is postoperative following the insertion of a ventriculoperitoneal shunt. The nurse should place the child in which of the following positions? A. On the nonoperative side B. A 45 deg head elevation C. Prone D. Supine
A. On the nonoperative side
The 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 a syndrome of inappropriate antidiuretic hormone secretion SIADH? A- sodium 148 B- urine specific gravity of 1.020 C- mental confusion D- weak peripheral pulses
C- mental confusion
A nurse is providing teaching to the parents of a toddler about the administration of a prescribed eye drops and eye ointment. Which of the following instructions should the nurse include? A- Apply the eye ointment within 30 minutes of your toddler Awakening in the morning B- apply the eye ointment from the outer canthus to the inner campus C- use one hand to pull the upper eyelid upward when instilling the eye drops D- administer the eye drops 3 minutes before the ointment
D- administer the eye drops 3 minutes before the ointment. The nurse should instruct the parents to administer the eye drops first and then wait 3 min before administering the eye ointment. This action provides adequate time and spacing for each separate medication to work.
The nurse is preparing to administer an immunization to a four-year-old child. Which of the following actions should the nurse plan to take? A- Place the child in a prone position for the immunization. B- request that the child's caregiver leave the room during the immunization C- administer the immunization using a 24-gauge needle D- inject the immunization slowly after aspirating for 3 seconds
C- administer the immunization using a 24-gauge needle. The nurse should administer an immunization for a 4-year-old child using a 24- gauge needle to minimize the amount of pain experienced by the toddler.
A nurse is collecting data from an infant who has otitis media (middle ear infection). The nurse should expect which of the following findings? A. Tugging on the affected ear lobe B. Bluish green discharge from the ear canal (there's usually no discharge, discharge only comes out if there's an opening in the eardrum) C. Increase in appetite(decreased appetite) D. Erythema and edema of the affected auricle (usually no redness in the affected auricle)
A. Tugging on the affected ear lobe
A nurse is caring for a child who has juvenile rheumatoid arthritis. Which of the following actions should the nurse take? A. Administer opioids on a schedule (Nsaids) B. Encourage the child to take daytime naps C. Apply cool compresses for 20 mins every hour D. Maintain night splints to the affected joint
D. Maintain night splints to the affected joint
A nurse is providing dietary teaching to the parent of a school-age child who has cystic fibrosis. Which of the following statements should the nurse make? A- You should offer your child high protein meals and snacks throughout the day B- your child should decrease dietary fats to less than 10% of her caloric intake C- your child will need to take a 1-gram sodium chloride tablet daily throughout her lifetime D- you should calculate your child carbohydrate needs based on her daily activities
A- You should offer your childhigh-proteinn meals and snacks throughout the day. The parent should provide a diet that is well-balanced and high in protein and calories. Children who have cystic fibrosis require a higher percentage of the recommended dietary allowances of all nutrients in order to meet their energy requirements. Children who have good nutritional intake have improved lung function and decreased risk of infection
A nurse is reinforcing reaching with a parent of a 1-month-old infant who is to undergo the initial surgery to treat Hirschsprung's disease (ganglionic megacolon, part of the colon isn't connected to the nerves or not functioning, so there will be the increased size of the colon and stool gets stuck in there). Which of the following statements should indicate to the nurse that the parent understands the goal of surgery?
A. "I'm glad that the ostomy is only temporary"
A nurse is caring for a child who is to receive percussion, vibration, and postural drainage. Which of the following actions should the nurse take first? A. Administer albuterol by nebulizer B. Percuss the upper posterior chest C. Perform vibration while the client exhales slowly through the nose. D. Instruct the client to cough
A. Administer albuterol by nebulizer
A nurse is caring for a child who has a suspected diagnosis of bacterial meningitis. Which of the following is the nurse's priority? A. Administer antibiotics when available B. Reduce environmental stimuli (because of the increase of ICP and can cause seizures) C. Document in take and output D. Maintain seizure precautions
A. Administer antibiotics when available
A nurse is reinforcing teaching with a parent of a child who has eczema. Which of th following instructions should the nurse include in the teaching A. Apply a cool wet compress to the affected area B. Launder clothing with fabric softener C. Give bubble baths every day D. Use a wool gloves in the winter time
A. Apply a cool wet compress to the affected area
A nurse is caring for a 6-month-old infant who is postoperative following a myringotomy. Which of the following pain assessment scales should the nurse use to determine the infants pain level? A. FLACC B. Oucher C. FACES D. Visual analog scale
A. FLACC
A nurse is collecting data from a child who has acute appendicitis. Which of the following findings should the nurse expect? A. WBC 17,000/mm3 B. Left lower quadrant abdominal pain C. Hyperactive bowel sounds D. Bradycardia (tachycardia)
A. WBC 17,000/mm3
A nurse in a provider's office is reinforcing teaching with a parent of a school age child who has pediculosis capitis. Which of the following instructions should the nurse include in the teaching? A. Wash all bed linens and dry them in a dryer for at least 20 min B. Apply permethrin cream twice daily C. Apply an anti-fungal treatment ointment once every day. D. Ensure that family pets are treated within 10 days
A. Wash all bed linens and dry them in a dryer for at least 20 min.
A nurse is caring for an infant who is dehydrated and requires IV therapy. The nurse should monitor the infant's response to therapy by performing which of the following actions? A. weighing the infants at the same time every day B. Taking the infant's vital signs every 2 hr. C. Measuring the infant's head circumference twice per day D. Counting the number of wet diapers every shift
A. weighing the infants at the same time every day
A nurse is caring for a toddler who has spastic (pyramidal) cerebral palsy. Which of thefollowing clinical manifestations should the nurse expect? Select all that apply. A- Negative Babinski reflex B- Ankle clonus C- exaggerated stretch reflexes D- uncontrollable movements of the face E- contractures
B- Ankle clonus C- exaggerated stretch reflexes E- contractures
A nurse is providing teaching to the family of a school-age child who has juvenile idiopathic arthritis. Which of the following instructions should the nurse include in the teaching? A- Limit the movement of the child large joints. B- Encourage the child to perform independent self-care. C- Provide the child with a soft mattress for sleeping D- Schedule a 2-hour daily nap for the child in the afternoon.
B- Encourage the child to perform independent self-care. The nurse should teach the family the importance of encouraging the child to perform independent self-care. This will minimize the child's pain while maximizing mobility.
A nurse is auscultating the lungs of an adolescent who has asthma. The nurse should identify the sound as which of the following? Click the audio button to listen. A- Biots respiration B- Chaney Stokes respiration C- tachypnea D - Bradypnea
C- tachypnea The nurse should identify the sound heard during auscultation as tachypnea, which is a rapid, regular breathing pattern. This breathing pattern often occurs with anxiety, fever, metabolic acidosis, or severe anemia.
A nurse in a provider's office is caring for a school-age child who has varicella. The parent asks the nurse when her child will no longer be contagious. Which of the following responses should the nurse make? A- When your child no longer has an increased temperature B- three days after you first noticed the rash appear on your child C- when your child's lesions are crusted, 6 days after they appear D- 2 - 3 weeks, when your child's lesions completely disappear
C- when your child lesions are crusted, 6 days after they appear
A nurse is caring for a school-age child who has a new plaster cast on her right arm. Which of the following actions should the nurse take? A. Position the casted arm in a dependent position B. Place a warm moist heat pack on the cast C. Administer diphenhydramine to relieve itching D. Move the casted arm with a firm grip
C. Administer diphenhydramine to relieve itching
The 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? A- Wheat bread B- vanilla malt C- barley soup D- rice pudding
D- rice pudding The nurse should instruct the parent that the child will remain on a lifelong gluten-free diet. The child cannot consume oats, rye, barley, or wheat, and sometimes lactose deficiency can be secondary to this disease. The nurse should recognize that rice pudding is a gluten-free food.
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? A- Instruct the parents to decrease the calcium in their toddler's diet B- prepare the toddler for chelation therapy C- refer at the family to Child Protective Services D- schedule the toddler for a yearly rescreening
D- schedule the toddler for a yearly rescreening.
A nurse in an emergency department is performing a physical assessment on a 2-week old male infant. Which of the following manifestations is the priority for the nurse to report to the provider? A- Excoriated scrotal area B- multiple capillary hemangiomas C- depressed posterior fontanel D- substernal retractions
D- substernal retractions
A nurse is caring for a 10-year-old child following a head injury. Which of the following findings should the nurse identify as an indication that the child is developing diabetes insipidus? A- Urine specific gravity of 1.045 B- sodium 155 C- blood glucose 45 D- urine output 35 ml per hour
B- sodium 155 A child who has a head injury can develop diabetes insipidus as a result ofpituitary hypo function leading to a deficiency of antidiuretic hormone.Under excretion of antidiuretic hormone leads to polyuria and polydipsia and possibly dehydration. With the excessive loss of free water, sodium levels rise above the expected reference range.
A nurse is reviewing the laboratory report of an infant who is receiving treatment for severe dehydration. The nurse should identify which of the following laboratory values indicates effectiveness of the current treatment. A- Potassium 2.9 mEq/L B- sodium 140 C- urine specific gravity 1.035 D- BUN 25 mg
B- sodium 140 The nurse should identify that a sodium level of 140 mEq/L is within the expected reference range and indicates the current treatment regimen the infant is receiving for dehydration is effective.
A nurse is creating an educational plan to teach parents about protecting their children fromsun burns. Which of the following instructions should the nurse plan to include? A- Choose a waterproof sunscreen with an SPF of at least 15 B- apply sunscreen liberally to infants over three months of age C- dress children in a loose weave polyester fabric prior to sun exposure D- reapply sunscreen every 4 hours
A- Choose a waterproof sunscreen with an SPF of at least 15.
A nurse is caring for a toddler who has a cast applied 2 hr ago due to multiple fractures of the right hand of the following findings should the nurse report immediately to the charge nurse? A. The fingers on the right hand have a capillary refill of 4 seconds B. The fingertips of the right hand are swollen and bruised C. The child is not attempting to move her right arm or fingers D. The parents report the child will not keep the arm elevated on the pillow
A. The fingers on the right hand have a capillary refill of 4 seconds.
A nurse is receiving a hand off report for a toddler who has a fractured right femur and is in 90-degree/90-degree traction. The nurse should expect to observe which of the following? A. Skin straps maintaining the affected leg in an extended position B. A skeletal pin in the distal end of the femur C. A padded sling under the knee of the affected leg D. The buttocks elevated slightly off of the bed
B. A skeletal pin in the distal end of the femur
A nurse is preparing an adolescent for a lumbar puncture. Which of the following actions should the nurse take? A- Place a cardiac monitor on the Adolescent prior to the procedure B- apply topical analgesic cream to the site one hour prior to the procedure C- keep the Adolescent in a semi Fowler's position for 4 hours following the procedure D- restrict fluids for 2 hours following the procedure
B- apply topical analgesic cream to the site one hour prior to the procedure The nurse should apply a topical analgesic to the lumbar site 60 min prior to the procedure to decrease the adolescent's pain while the lumbar needle is inserted.
A nurse is assessing a three-year-old toddler at a well-child visit. Which of the following manifestations should the nurse to the provider? A- Blood pressure 90/ 50 B- respiratory rate 45/min C- weight 14.5 kg or 32 lb D- heart rate 110/min
B- respiratory rate 45/min A respiratory rate of 45/min is above the expected reference range for a 3-year-old toddler and can indicate respiratory dysfunction and acute respiratory distress. Therefore, the nurse should report this finding to the provider immediately.
A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions is the nurse's priority? A. Place the child on a no salt added diet B. Check the Childs weight daily C. Educate the parents about potential complications D. Maintain a saline lock (IV access that is attached to any fluids. For emergency)
B. Check the Child's weight daily
A nurse is reviewing the dietary choices of an adolescent who has iron deficiency anemia. the nurse should identify that which of the following menu Do items have the highest amount of iron? A- 1⁄2 cup whole milk B- 1 cup orange juice C- 1⁄2 cup raisins D- one cup raw carrots
C- 1⁄2 cup raisins
The nurse is providing discharge teaching to the parent of an 18-month old toddler who has dehydration as a result of acute diarrhea. Which of the following statements by the parent indicates an understanding of the teaching? A- I will offer my child small amounts of fruit juice frequently B- I will avoid giving my child solid foods until his diarrhea has stopped C- I will monitor my child's number of wet diapers D- I will give my child polyethylene glycol daily for 7 days
C- I will monitor my child's number of wet diapers. The nurse should teach the parent to closely monitor the child's number of wet diapers. Monitoring the number of wet diapers per day is the best way for the parent to monitor adequate output and hydration status.
A nurse is caring for a hospitalized preschooler. The child's mother is going home for a few hours while another relative stay with the child. Which of the following statements should the nurse make to explain to the child when her mother will return? A- Your mommy will be back at 7 p.m. B- your mommy will be back after she takes care of your brother C- your mommy will be back in the morning D- your mommy will be back after you eat
D- your mommy will be back after you eat.
A nurse is teaching the parents of a newborn about ways to prevent sudden infant death syndrome SIDS. Which of the following instructions should the nurse include? A- Place the infant in a prone position to sleep. B- Allow the infant to sleep on a large pillow. C- User soft mattress in the infant's crib. D- Give the infant a pacifier at bedtime.
D- Give the infant a pacifier at bedtime. The nurse should inform the parent that protective factors against SIDS include breastfeeding and the use of a pacifier when the infant is sleeping.
nurse is creating a plan of care for an infant who has an epidural hematoma with a skull fracture. Which of the following actions should the nurse include in the plan? A- Position the infant side lying with her head at a 0 - 5 degree angle B- monitor the infant for tachycardia to prevent brain stem herniation C- suction the infant snares every two hours while awake to maintain patency D- implements seizure precautions for the infants
D- Implement seizure precautions for the infants. The nurse should implement seizure precautions for an infant who has an epidural hematomas' a safety measure.
A nurse is planning care for a child who has severe diarrhea. which of the following actions is the nurse's priority? A. Introduce a regular diet B. Rehydrate C. Maintain fluid therapy D. Assess fluid balance
D. Assess fluid balance
A school nurse is screening an 11-year-old child for idiopathic scoliosis. Which of the following instructions should the nurse give the child for this examination? A. Lie prone on the examination table B. Touch your chin to your chest and then look up at the ceiling C. Turn to the side and remain in a relaxed position D. Bend forward from the waist with your head and arms downward
D. Bend forward from the waist with your head and arms downward
A nurse is caring for a preschool-age child who has croup. Which of the following findings should the nurse report to the provider? A. Barky cough B. Paroxysmal attacks of laryngeal spasm at night C. Hoarseness D. Drooling
D. Drooling
A nurse is caring for a preschooler who has been receiving IV fluids via a peripheral IV catheter. When preparing a to discontinue the IV fluids and catheter, which of the following actions should the nurse plan to take? Place the steps in order of performance. A- remove the tape securing the catheter B- turn off the IV pump C- occlude the IV tubing D- apply pressure over the catheter insertion site
B- turn off the IV pump C- occlude the IV tubing A- remove the tape securing the catheter D- apply pressure over the catheter insertion site
A nurse is caring for a school-age child who has a fracture to the right femur. Which of the following findings is the nurse priority? A. 2+ right pedal pulse B. respiratory rate 24/min C. capillary refill less than 2 seconds D. tingling in the right foot
D. tingling in the right foot
A nurse is providing teaching to the parent of a school-age child who has oral candidiasis and is to begin taking oral Nystatin. Which of the following instructions should the nurse include? A- Check the medication prior to administration B- provide the medication through a straw C- rinse the child's mouth with water immediately after giving the medication D- next the medication with applesauce If the child dislikes the taste
A- Check the medication prior to administration. The nurse should instruct the parent to shake the medication prior to administration in order to disperse the medication evenly within the suspension.
A nurse is assessing the pain level of a three-year-old toddler. Which of the following pain assessment scales should the nurse use? A- FACES Pain rating scale B- numeric pain rating scale C- CRIES pain assessment scale D- non communicating children's pain checklist
A- FACES Pain rating scale. The nurse should use the FACES pain rating scale for pediatric clients who are 3 years old and older. This scale allows the toddler to point to the face that depicts the current level of pain. The nurse can then determine the need for pain management.
A nurse is assessing a client who has a new diagnosis of celiac disease. Which of the following clinical manifestations should the nurse expect? A- Steatorrhea B- projectile vomiting C- sunken abdomen D- weight gain
A- Steatorrhea The nurse should realize that clients who have celiac disease are unable to digest gluten. This will cause damage to the cells in the bowel, leading to malabsorption, steatorrhea, and diarrhea.
A nurse in a provider's office is preparing to administer immunizations to a toddler during a well-child visit. Which of the following actions should the nurse plan to take? Prescriptions: tuberculin skin test TSTmeasles mumps rubella vaccine inactivated influenza vaccine diphtheria, tetanus, and pertussis DTaP vaccine vital signs respiratory rate 24/ minute heart rate 115/ minute temperature 37.4 degrees Celsius or 99.3 degrees FahrenheitHistory and physical Age 12 months is 9 height 71.1 CMor 28-in allergies neomycin - anaphylactic reaction caregiver reports rhinitis with clear nasal drainage for 2 days occasional nonproductive coughs for 2 days history of asthma. A- Withhold the measles mumps and rubella MMR vaccine B- withhold the DTaP vaccine C- withhold the influenza vaccine D- withhold the tuberculin skin test TST
A- Withhold the measles mumps and rubella MMR vaccine
A nurse is providing discharge teaching to the parent of a school-age child who has moderate persistent asthma. Which of the following instructions should thenurse include? A- You should give your child his salmeterol inhaler every 4 hours when he is having an acute episode of wheezing. B- You should monitor your child's weight weekly while he is receiving inhaled corticosteroid therapy C- pulmonary function test will be performed every 12 to 24 months to evaluate how yourchild is responding to therapy D- when using the peak expiratory flow meter, record your child average of three readings
C- pulmonary function test will be performed every 12 to 24 months to evaluate how your child is responding to therapy. The nurse should inform the parent that her child will need pulmonary function tests every 12 to 24 months to evaluate the presence of lung disease and how the child is responding to the current treatment regimen. As children grow, sometimes their symptoms can improve or decline and treatment needs to change accordingly
A nurse is collecting data from a 3-year-old child who has acute diarrhea and dehydration. Which of the following findings indicates that oral rehydration therapy has been effective A. Heart rate 130/min B. respiratory 24/min C. urine specific gravity 1.015 (1.010-1.015) higher urine specific gravity is dehydration D. Capillary refill greater than 3 seconds
C. urine specific gravity 1.015 (1.010-1.015) Higher urine specific gravity is dehydration
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 clinical manifestations should the charge nurse include as suggestive of potential? A- Recurrent urinary tract infections B- Symmetric burns of the lower extremities C- growth failure D- lack of subcutaneous fat
B- Symmetric burns of the lower extremities
A nurse is assessing a school-age child immediately post-operative following a perforated appendix repair. Which of the following findings should the nurse expect?A- Purulent nasogastric drainage B- absence of peristalsis C- passage of dark red stool with mucus D- WBC of 6000
B- absence of peristalsis
A nurse is collecting data from an 8-month-old infant who has increased intracranial pressure (ICP) which of the following manifestations should the nurse expect? A. Insomnia B. Bulging fontanel C. Low-pitched cry D. Positive Babinski reflex
B. Bulging fontanel
A nurse is assessing an adolescent who received a sodium polystyrene sulfonate enema. Which of the following findings indicates effectiveness of the medication? A- The Adolescents reports in absence of nausea and vomiting B- the client experiences onset of loose stools within 15 minutes of administration C- The Adolescents serum potassium level is 4.1 D- the Adolescent has a blood pressure of 86/ 52
C- The Adolescents serum potassium level is 4.1
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? A- Apply topical antimicrobial ointment to the child wound B- place a mesh gauze dressing over the child wound C- administer an analgesic to the child D- initiate prophylactic antibiotic therapy for the child
C- administer an analgesic to the child. Hydrotherapy for debridement of a wound is an extremely painful procedure which requires analgesia and/or sedation. When pain is controlled, it leads to Downloaded by Flor Mendoza ([email protected]) Page 5 of 27 reduced physiological demands on the body caused by stress and decreases the likelihood of children developing depression and post-traumatic stress disorder.
A school nurse is assessing a school-age child blood pressure while he is seated in a chair. The child starts to experience a tonic-clonic seizure. Which of the following actions should the nurse take first? A- Clear the immediate area around the child of hazardous objects B- loosen the child restrictive clothing C- assist the child to a side-lying position on the floor D- apply an oxygen mask to the child
C- assist the child to a side-lying position on the floor. The greatest risk to this child is aspiration, occlusion of the airway, and bodily injury from falling out of the chair. The nurse should ease the child down to floor in a side-lying position immediately. This position enables the child's secretions to drain from the mouth, preventing aspiration, and maintaining a patentairway.
A nurse is contributing to the plan of care for a 2-month-old infant who has just undergone cleft palate repair. The nurse should contribute which of the following interventions to the clients plan of care? A. Feed the infant half-strength formula for the first 48 hr. B. Remove elbow restraints while the infant is sleeping (do not remove the restraint unattended because when they sleep they can still touch the operative site, u can remove it for a short period of time to just monitor) C. Keep the infant in a side-lying position D. Administer pain medication PRN for the first 48 hr. (it should not be PRN it should be scheduled)
C. Keep the infant in a side-lying position.
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 priorityaction by the nurse? A- Elevate the head of the child's bed B- insert a large-bore IV catheter for the child C- determine the allergen that caused the child's reaction D- administer IM epinephrine to the child
D- administer IM epinephrine to the child When using the urgent vs no urgent approach to client care, the nurse determinesthat the priority action is administering IM epinephrine to the child. During an anaphylactic reaction, histamine release causes bronchoconstriction and vasodilation. This is an emergency becauseultimately it causes decreased blood return to the heart
A nurse is creating a plan of care for a toddler who has minimal change nephrotic syndrome mcns and 3 + pitting edema. Which of the following interventions should the nurse include in the plan? A- Encourage an increased fluid intake for the toddler B- place the child in an Airborne infection isolation room C- increase the toddler's dietary sodium intake D- administer corticosteroids to the toddler
D- administer corticosteroids to the toddler. The nurse should recognize that corticosteroids are the treatment of choice for providers caring for children who have MCNS. Therefore, the nurse should include administration of prescribed corticosteroids in the plan of care for this toodler.
A nurse is performing hearing screenings for children at a community health fair. Which of the following children should the nurse refer to a provider for amore extensive hearing evaluation? A- A toddler who is 18 months old and has unintelligible speech B- an infant who is 3 months old and has an exaggerated startle response C- a preschooler who is 4 years old and prefers playing with others rather than alone D- an infant who is 8 months old and is not yet making babbling sounds
D- an infant who is 8 months old and is not yet making babbling sounds. Answer- dThe nurse should refer an infant who is not making babbling sounds by the age of 7 months to a provider for more extensive evaluation of hearing.
A nurse is creating a plan of care for a newly admitted adolescent who has bacterial meningitis. How long should the nurse plan to maintain the Adolescent in droplet precautions? A- Until the Adolescent is afebrile B- for 7 days following an admission to the facility C- until the Adolescent has a negative blood cultureD- for 24 hours following initiation of antimicrobial therapy
D- for 24 hours following initiation of antimicrobial therapy.
The nurse is providing teaching about Social Development to the parents of a preschooler. Which of the following play activities should the nurse recommendfor the child? A- Play pat-a-cake B- using a push pull toy C- creating a scrapbook D- playing dress-up
D- playing dress-up
a nurse is caring for a child following an open reduction and internal fixation of a fractured femur and application of a cast. The cast has a window cut in it for viewing of the incision. Which of the following actions should the nurse take first? A. Remove the window and view the incision B. Turn the client so the cast will dry on all sides C. Medicate the client for pain D. Perform neurovascular checks of the affected extremity.
D. Perform neurovascular checks of the affected extremity.
A nurse is assisting with the care of a school-age child who has respiratory failure due to pneumonia. Which of the following positons should the nurse encourage to allow maximal lung expansions? A. ProneB. Supine C. Side lying D. Upright
D. Upright
The 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% B- hemoglobin 13.5 g C- WBC 8000 D- platelet 250,000
A- Hematocrit 28% The nurse should recognize that this hematocrit level is below the expected reference range fora school-age child. The child can exhibit fatigue, lightheadedness, tachycardia, dyspnea, and pallor due to the decreased oxygen- carrying capacity.
A nurse is providing teaching about car seat use to the mother of a six-month- old infant. Which of the following statements by the mother indicates an understanding of the teaching? A- I should secure the car seat using lower anchors and tethers instead of the seat belt B- I should position the car seat harness one inch above my baby's shoulders C- I will make sure that the car seat is placed at a 90-degree angleD- I will pad my baby's car seat with a blanket for traveling long distances
A- I should secure the car seat using lower anchors and tethers instead of the seat belt. Lower anchors and tethers, or the LATCH child safety seat system, should be used to secure an infant's car seat in the vehicle. This system provides anchors between the front cushion and the back-rest for the car seat. Therefore, if this system is available, the seatbelt does not have to be used.
A nurse is assessing an infant who has pneumonia. Which of the following findings is the priority for the nurse to report to the provider? A- Nasal flaring B- WBC 11,300 C- diarrhea D- abdominal distension
A- Nasal flaring When using the airway, breathing, circulation approach to client care, the nurse should place the priority on nasal flaring. Nasal flaring indicates that the infantis experiencing acute respiratory distress.
A nurse is planning developmental activities for a newly admitted 10-year-old child who has neutropenia. Which of the following actions should the nurse plan to take? A- Provide the child with a book about Adventure B- arrange frequent visits from family members and peers C- give the child a large piece puzzle D- use puppet to entertain the child
A- Provide the child with a book about Adventure
A nurse is teaching the parents of a toddler who has cognitive impairment about toilet training. which of the following instructions should the nurse include in the teaching? A- Scold the child when he has a toileting accident B- award the child with a sticker when he sits on the potty chair C- play the child favorite song while teaching him to use the potty chair D- teach multiple steps of the skill at the same time
B- award the child with a sticker when he sits on the potty chair.
A nurse in the emergency department is caring for a toddler who has partial thickness burns on his right arm. Which of the following actions should the nurse take? A- Insert a nasogastric tube B- initiate prophylactic antibiotics therapy C- cleanse the affected area with mild soap and water D- apply a topical corticosteroid to the affected area
C- cleanse the affected area with mild soap and water. The nurse should wash the affected area with mild soap and water to remove any loose tissue that could cause infection.
A school nurse is assessing an adolescent who presents with multiple Burns in various stages of healing. Which of the following behaviors should the nurse identify as suggestive of possible physical abuse? A- Expresses a reluctance to leave home B- provides a detailed description of how the burns occurred C- denies discomfort during assessment of injuries D- describes strong relationships with peers
C- denies discomfort during assessment of injuries.
A nurse at an urgent care clinic is assessing an adolescent client who has an upper respiratory tract infection. Which of the following findings should the nurse recognize as a manifestation of pertussis? A- Inflamed throat with exudate B- purulent eye drainage C- dry, hacking cough D- koplik spots on buccal mucosa
C- dry, hacking cough The nurse should recognize that a dry, hacking cough is a manifestation of pertussis. This disease usually begins with indications of an upper respiratory tract infection, which includes a dry, hacking cough that is sometimes more severeat night.
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? A- Obtain a sputum specimen B- perform an allen test C- perform a finger stick D- obtain a stool specimen
C- perform a finger stick. The nurse should perform a finger stick on a toddler as a component of the sickle- turbidity test. If the test is positive, hemoglobin electrophoresis is required to distinguish between children who have the genetic trait and children who have the disease.
A nurse is caring for a child who has tinea pedis. The childs parents ask the nurse what this infection is commonly called. The nurse should respond with which of the following common names A. Shingles B. Athletic foot C. Fever blisters D. Pinworms
D. Pinworms