ATI PEDS PREP
A nurse is reviewing the laboratory results of a child who has experienced diarrhea for the past 24 hr. Which of the following values for urine specific gravity should the nurse expect? A. 1.010 B. 1.035 C. 1.020 D. 1.005
B. 1.035 Rationale: 1.035 is a concentrated specific gravity, which is an expected value for a child who is dehydrated; therefore, this is an expected urine specific gravity for a child who has experienced diarrhea for 24 hr.
A nurse is assessing the pain level of a 3-year-old child who is postoperative following abdominal surgery. Which of the following pain scales should the nurse use? A. Word graphic rating scale B. Color tool C. FACES pain rating scale D. Numeric scale
C. FACES pain rating scale
A nurse is caring for a child who is postoperative following a tonsillectomy. Which of the following findings is the nurse's priority? A. Nausea B. Hoarse voice C. Frequent swallowing D. Sore throat
C. Frequent swallowing
A nurse is preparing to administer an intramuscular injection to a 2-month-old infant. In which of the following sites should the nurse plan to administer the injection? A. Vastus lateralis B. Dorsogluteal C. Deltoid D. Abdomen 5 cm (2 in) from the umbilicus
A. Vastus lateralis
A nurse is assessing pain in a 3-year-old child following a tonsillectomy. Which of the following rating scales should the nurse use to determine the child's pain level? A. Word-Graphic Rating Scale B. Color Tool C. Poker Chip Tool D. FACES Rating Scale
D. FACES Rating Scale
A nurse is teaching the parent of a toddler about home safety. Which of the following statements by the parent indicates an understanding of the teaching? A. " I lock my medications in the medicine cabinet." B. "I keep my child's crib mattress at the highest level." C. "I turn pot handles to the side of my stove while cooking. D. "I will give my child syrup of ipecac if she swallows something poisonous."
A. " I lock my medications in the medicine cabinet." Rationale: Locking up medications and other potential poisons prevents access. Toddlers have improved gross and fine motor skills that allow for further exploration of the environment and possible access to hazardous substances.
A nurse is caring for a child who has a possible intussusception. The parents of the child ask the nurse how the diagnosis is made. Which of the following responses should the nurse make? A. "An abdominal ultrasound will confirm the pocket in the intestine." B. "Genotyping will be done to identify this condition." C. "A biopsy will be done on a small amount of tissue from the colon." D. "An upper Gl series should identify the area involved."
A. "An abdominal ultrasound will confirm the pocket in the intestine." Rationale: Intussusception is the invasion of one part of the intestine into the other, creating a pocket. The presence of an intussusception is confirmed by an abdominal x-ray, ultrasound, or CT scan.
A nurse is teaching the parent of a preschool-age child about the treatment for pinworms. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will give my child a dose of albendazole today and again in 2 weeks." B. "I will collect specimens immediately after my child has a bowel movement." C. "I will give my child a tub bath twice each day." D. "I will place my child's bed linens in a sealed plastic bag for 7 days."
A. "I will give my child a dose of albendazole today and again in 2 weeks." Rationale: The nurse should instruct the parent to repeat the dose of albendazole in 2 weeks to completely eradicate the parasite and prevent reinfection.
A nurse is providing teaching to the parents of a school-age child who has type 1 diabetes mellitus about management of hypoglycemia. Which of the following responses by the parents indicates an understanding of the teaching? A. "I will make sure my child drinks 240 mL (8 oz) of milk as soon as possible." B. "I will give my child 2 units of regular insulin." C. "I will insist that my child lies down to rest for 30 minutes." D. "I will check my child's urine for glucose twice daily."
A. "I will make sure my child drinks 240 mL (8 oz) of milk as soon as possible." Rationale: Giving the child 10 to 15 g of simple carbohydrates, such as 240 mL (8 oz) of milk, will elevate the blood glucose level and alleviate the hypoglycemia.
A nurse is providing teaching to the parent of a 2-year-old toddler about nutrition. Which of the following statements by the parent indicates an understanding of the teaching? A. "My child should consume 1,000 calories per day." B. "My child should have 4 ounces of protein per day." C. "I should give my child 32 ounces (4 cups) of milk per day." D. "I should feed my child 4 ounces (1/2 cup) of vegetables per day."
A. "My child should consume 1,000 calories per day."
A nurse is caring for a child who has bacterial endocarditis. The child is scheduled to receive moderate term antibiotic therapy and requires a peripherally inserted central catheter (PICC). Which of the following statements should the nurse include when teaching the child's parent? A. "The PICC line will last several weeks with proper care." B. "The public health nurse will rotate the insertion site every 3 days." C. "You will need to make certain the arm board is in place at all times." D. "Your child will go to the operating room to have the line placed."
A. "The PICC line will last several weeks with proper care." Rationale: PICC lines are the preferred venous access device for short to moderate term IV therapy. They can remain in place for long periods with proper care.
A nurse is caring for a child who is receiving treatment for diabetic ketoacidosis and has a current blood glucose level of 250mg/dL. Which of the following actions should the nurse take? A. Administer 5% dextrose in 0.9% sodium chloride by continuous IV infusion. B. Give potassium as a rapid IV bolus. C. Administer 3 units of ultralente insulin subcutaneously. D. Obtain an HbA1c level stat.
A. Administer 5% dextrose in 0.9% sodium chloride by continuous IV infusion. Rationale: When the child's blood glucose level falls between 250 and 300 mg/dL, the nurse should begin IV infusion of 5% or 10% dextrose in 0.9% sodium chloride. The goal is to maintain blood glucose levels between 120 and 240 mg/dL. If dextrose is not added, hypoglycemia might occur.
A nurse is providing teaching to the parents of a 4-year-old child about fine motor development. Which of the following tasks should the nurse include in the teaching as an expected finding for this age group? A. Copies a circle B. Cuts foods using a table knife C. Begins writing in cursive D. Prints first and last name clearly
A. Copies a circle Rationale: The nurse should explain that copying a circle is a skill achieved by the age of 4 years.
A nurse is teaching the parent of an infant about food allergens. Which of the following foods should the nurse include as being the most common food allergy in children? A. Cow's milk B. Wheat bread C. Corn syrup D. Eggs
A. Cow's milk Rationale: According to evidence-based practice, the nurse should instruct the parent that cow's milk is the most common food allergy in children. Some children are sensitive to the protein, called casein, found in cow's milk. They have difficulty metabolizing the casein and are, therefore, allergic to cow's milk.
A nurse at a clinic is preparing to administer immunizations to a 5-year-old child. Which of the following immunizations should the nurse plan to give? A. Diphtheria, tetanus, and pertussis (DaP) B. Pneumococcal (PC) C. Haemophilus influenza type B (Hib) D. Hepatitis B (Hep B)
A. Diphtheria, tetanus, and pertussis (DaP) Rationale: Children should receive booster doses of the DaP immunization between the ages of 4 and 6. It is around this age that blood titers drop due to decreasing antibodies.
A nurse providing teaching about promoting sleep with the parent of a 3-year-old toddler. Which of the following information should the nurse include? A. Follow a nightly routine and established bedtime. B. Encourage active play prior to bedtime. C. Let the child remain awake until tired enough to go to sleep. D. Reward the child with a food treat just prior to sleep if the child goes to bed on time.
A. Follow a nightly routine and established bedtime. Rationale: Preschool-age children test limits. Consistency in approach to bedtime is very important. Bedtime is more likely to be pleasant for everyone if a routine is established and followed every night.
A nurse at a pediatric clinic is assessing a 5-month-old infant during a well-child visit. Which of the following findings should the nurse report to the provider? A. Head lags when pulled from a lying to a sitting position B. Absence of startle and crawl reflexes C. Inability to pick up a rattle after dropping it D. Rolls from back to side
A. Head lags when pulled from a lying to a sitting position Rationale: At the age of 5 months, the infant should have no head lag when pulled to a sitting position; therefore, the nurse should report this finding to the provider.
A nurse is assessing a 12-month-old male infant's vital signs during a well-child visit. The infant is in the 90th percentile of height. Which of the following findings should the nurse report to the provider? A. Heart rate 175/min B. Respiratory rate 26/min C. Blood pressure 88/40 mm Hg D. Temperature 37.6° C (99.7° F)
A. Heart rate 175/min Rationale: A heart rate of 175/min is above the expected reference range for a 12-month-old Infant; therefore, the nurse should report this finding to the provider.
A nurse is teaching a newly hired nurse about the care of an infant who is postoperative following myelomeningocele repair. The nurse should teach the newly hired nurse to monitor the infant for which of the following complications? A. Hydrocephalus B. Congenital hypotonia C. Otitis media D. Osteomyelitis
A. Hydrocephalus Rationale: In the surgical repair of the myelomeningocele, the pathway for the cerebral spinal fluid is altered; therefore, the infant is at risk for hydrocephalus and the nurse should monitor the infant for this condition.
A nurse is providing dietary teaching to the parent of a child who has cystic fibrosis. Which of the following dietary recommendations should the nurse make? A. Increase the child's protein intake. B. Decrease the child's calorie intake. C. Increase the child's fiber intake. D. Decrease the child's salt intake.
A. Increase the child's protein intake. Rationale: The nurse should recommend an increase in protein intake for the child who has cystic fibrosis. These children require up to 150% of the recommended daily allowances to meet their nutritional needs.
A nurse is assessing a toddler who has measles (rubeola). Which of the following findings should the nurse expect? A. Koplik spots B. Parotitis C. Strawberry tongue D. Paroxysmal cough
A. Koplik spots Rationale: Koplik spots are small, irregular oral lesions with a bluish-white center and are characteristic of measles (rubeola). Koplik spots appear about 2 days before the maculopapular rash appears and are accompanied by manifestations of fever, malaise, conjunctivitis, and other cold manifestations.
A nurse is caring for a 2-day-old infant who has a myelomeningocele. Which of the following actions should the nurse take? A. Monitor the infant's head circumference. B. Position the infant supine. C. Place the infant under a radiant warmer. D. Tape a piece of plastic over the protruding membranes.
A. Monitor the infant's head circumference. Rationale: Infants who have myelomeningocele have an increased risk for hydrocephalus. Measuring the infant's head circumference helps to determine any increase.
A nurse is planning care for a 10-month-old infant who has suspected failure to thrive (FTT). Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Observe the parents' actions when feeding the child. B. Maintain a detailed record of food and fluid intake. C. Follow the child's cues as to when food and fluids are provided. D. Sit beside the child's high chair when feeding the child. E. Play music videos during scheduled meal times.
A. Observe the parents' actions when feeding the child. B. Maintain a detailed record of food and fluid intake. Rationale: Observing the parents' actions when feeding the child is correct. Inappropriate feeding techniques and meal patterns provided by parents can contribute to a child's growth failure. Maintaining a detailed record of food and fluid intake is correct. A nutritional goal for the child who has suspected FTT is to correct nutritional deficiencies, which can be identified by recording all food and fluid intake.
A nurse is providing teaching to an adolescent who has a fiberglass arm cast. Which of the following instructions should the nurse include in the teaching? A. Place a plastic bag over the cast when showering. B. Insert a dull knitting needle into the cast to rub itchy skin. C. Exercise fingers every 8 hr for the first 24 hr. D. Draw on the cast using magic markers.
A. Place a plastic bag over the cast when showering. Rationale: The nurse should instruct the adolescent to keep the cast dry by placing a plastic bag over it while showering. Although water will not damage the fiberglass cast, water can enter the openings of the cast and result in maceration of the skin.
A nurse is assessing a 6-year-old child at a well-child visit. Which of the following findings requires further assessment by the nurse? A. Presence of sparse, fine pubic hair B. Decreased head circumference compared to full height C. Increased leg length related to height D. Presence of a loose, central incisor
A. Presence of sparse, fine pubic hair Rationale: The development of sexual characteristics prior to the age of 9 years in boys, and 8 years in girls, is an indication of precocious puberty and requires further evaluation.
A nurse is preparing a school-age child for a tonsillectomy. Which of the following actions should the nurse take? A. Schedule the child for a preoperative visit to the facility. B. Inform the child he will be put to sleep during the procedure. C. Read the child a story about a cartoon character having a similar operation. D. Tell the child the appointment is to have his throat checked.
A. Schedule the child for a preoperative visit to the facility.
A nurse is caring for a preschool-age child who is dying. Which of the following findings is an age-appropriate reaction to death by the child? (Select all that apply.) A. The child views death as similar to sleep. B. The child is interested in what happens to his body after death. C. The child recognizes that death is permanent. D. The child believes his thoughts can cause death. E. The child thinks death is a punishment.
A. The child views death as similar to sleep. D. The child believes his thoughts can cause death. E. The child thinks death is a punishment. Rationale: The child views death as similar to sleep is correct. Preschool-age children might make this comparison. The child believes his thoughts can cause death is correct. Preschool-age children believe that their thoughts and wishes can make things happen since they are egocentric. This is one reason why the death of a family member can be very difficult for a child at this age. The child thinks death is a punishment is correct. Preschool-age children sometimes believe that death is the result of guilt or punishment due to something they have done, said, or thought.
A nurse is planning to collect a specimen from a male infant using a urine collection bag. Which of the following actions should the nurse take? A. Wash and dry the infant's genitalia and perineum thoroughly. B. Apply a small coating of water-soluble lubricant to the skin of the infant's perineal area. C. Avoid placing the scrotum inside the collection bag. D. Wait several hours after positioning the device before checking it.
A. Wash and dry the infant's genitalia and perineum thoroughly. Rationale: This is the method used to obtain a routine urine specimen of any sort in a child who is not toilet trained. The skin should be washed and dried to promote application of the adhesive of the collection device.
A nurse is assessing a 2-month-old infant who has a ventricular septal defect. Which of the following findings should the nurse report to the provider? A. Weight gain of 1.8 kg (4 lb) B. Heart rate 125/min C. Soft, flat fontanel D. Systemic murmur
A. Weight gain of 1.8 kg (4 lb) Rationale: A 4 lb weight gain indicates increased fluid and worsening of the child's heart failure; therefore, the nurse should report this finding to the provider.
A nurse is providing teaching to an adolescent who has scoliosis and a new prescription for a Boston brace. Which of the following responses by the adolescent indicates an understanding of the teaching? A. "I can take my brace off to sleep every night at bedtime." B. "I can take my brace off for about an hour daily to shower." C. "I should loosen the straps on my brace if it is rubbing my skin." D. "I should place the pads of brace against my skin with a t-shirt over them."
B. "I can take my brace off for about an hour daily to shower." Rationale: The nurse should instruct the child to wear the brace for 23 hr each day and to only remove it for showering or participating in physical therapy.
A nurse is teaching parents of a 10-year-old child who has iron-deficiency anemia. Which of the following statements by a parent indicates an understanding of the teaching? A. "I will give my child an iron tablet once each day at bedtime." B. "I will administer the iron tablet with orange juice." C. "I will encourage my child to take an antacid with the iron tablet." D. "I will crush the iron tablet prior to giving it to my child."
B. "I will administer the iron tablet with orange juice."
A nurse is providing teaching about immunizations to the parents of a severely immunocompromised child who has human immunodeficiency virus (HIV). Which of the following statements should the nurse include in the teaching? A. "Your child's immunizations today will be half-doses." B. "The pneumococcal and infuenza vaccines are recommended for your child." C. "Immunizations will be delayed until your child tests HIV negative." D. "Your child will need to start the immunization schedule over once his laboratory values are within reference range."
B. "The pneumococcal and infuenza vaccines are recommended for your child." Rationale: Immunization against common childhood illnesses, including the influenza and pneumococcal disease, is recommended for all children exposed to and infected with HIV.
A nurse is performing a physical assessment on a 6-month-old infant. Which of the following highlight reflexes should the nurse expect to find? A. Stepping B. Babinski C. Extrusion D. Moro
B. Babinski Rationale: The Babinski reflex, which is elicited by stroking the bottom of the foot and causing the toes to fan and the big toe to dorsiflex, should be present until the age of 1 year. Persistence of neonatal reflexes might indicate neurological deficits.
A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions should the nurse take? A. Maintain the child on strict bed rest. B. Check the child's blood pressure every 4 hr. C. Administer albumin to the child every 8 hr. D. Provide the child with a low-carbohydrate diet.
B. Check the child's blood pressure every 4 hr. Rationale: Monitor for hypertension in these patients
A nurse in the emergency department is caring for a 2-year-old child who was found by his parents crying and holding a container of toilet bowl cleaner. The child's lips are edematous and inflamed, and he is drooling. Which of the following is the priority action by the nurse? A. Remove the child's contaminated clothing. B. Check the child's respiratory status. C. Administer an antidote to the child. D. Establish IV access for the child.
B. Check the child's respiratory status. Rationale: ABCs
A nurse is developing a plan of care for a school-age child who underwent a surgical procedure that resulted in a temporary loss of vision. Which of the following interventions should the nurse include in the plan of care? A. Assign an assistive personnel to feed the child B. Explain sounds the child is hearing C. Have the child use a cane when ambulating D. Rotate nurses caring for the child
B. Explain sounds the child is hearing Rationale: The noises in a facility can be frightening to child who is experiencing a sensory loss. It is important to explain these noises to allay the child's fears.
A nurse on a pediatric unit is reviewing the health record of a child who is demonstrating increasing levels of stress after admission. The nurse should identify which of the following findings as a risk factor for a stress-related reaction to hospitalization? A. Age 10 B. Frequent hospitalizations C. Parent bonding with child D. Calm, quiet demeanor
B. Frequent hospitalizations Rationale: Children who experience multiple and frequent hospitalizations are at an increased risk for stress-related reactions to hospitalization.
A nurse is preparing to administer a liquid medication to an infant. Which of the following actions should the nurse take? A. Administer the medication while the infant is supine B. Give the medication at the side of the infant's mouth C. Add the medication to a full bottle of the infant's formula D. Administer the medication slowly while holding the nares closed
B. Give the medication at the side of the infant's mouth Rationale: When administering medications to an infant, a needleless oral syringe or medicine dropper is placed in the side of the mouth (buccal cavity alongside the tongue) to prevent gagging and aspiration.
A nurse is reviewing the laboratory report of a toddler who is receiving chemotherapy for leukemia. Which of the following laboratory values should the nurse report to the provider? A. Platelets 150,000/mm B. Hgb 6g/dL C. WBC 6,000/mm3 D. Potassium 4.5 mEg/L
B. Hgb 6 g/dL Rationale: This hemoglobin level is below the expected reference range and is indicative of anemia; therefore, the nurse should report this finding to the provider.
A nurse is assessing a 9-month-old infant during a well-child visit. Which of the following findings indicates that the infant has a developmental delay? A. Creeps on hands and knees B. Inability to vocalize vowel sounds C. Uses crude pincer grasp D. Stands by holding onto support
B. Inability to vocalize vowel sounds Rationale: The infant should begin vocalizing vowel sounds at the age of 7 months, and by the age of 10 months, be able to say at least one word
A nurse is caring for a 4-year-old child who has pneumonia. The child's mother left 2 hr ago and he is currently experiencing the separation anxiety stage of despair. Which of the following findings should the nurse expect? A. Crying and screaming B. Inactive and thumb sucking C. Shows interest in toys around him D. Attempts to escape and find parent
B. Inactive and thumb sucking Rationale: A child who is sucking his thumb and refusing to eat or drink is displaying manifestations of the second stage of separation anxiety, which is despair.
A home health nurse is developing a plan of care for the parents of a toddler who has hemophilia. Which of the following instructions should the nurse include in the plan? A. Administer low-dose aspirin for pain. B. Inspect the toddler's toys for sharp edges. C. Perform passive range-of-motion to the affected joint during a bleeding episode. D. Avoid contact with people who have respiratory infections.
B. Inspect the toddler's toys for sharp edges.
A nurse is providing teaching to the parents of an infant who has acute otitis media about how to administer antibiotic eardrops. Which of the following instructions should the nurse include? A. Chill the medication prior to administration. B. Massage the anterior area of the infant's ear following administration. C. Hyperextend the infant's neck during administration. D. Pull the auricle up and back during medication administration.
B. Massage the anterior area of the infant's ear following administration.
A nurse is caring for an 18-year-old adolescent who is up-to-date on immunizations and is planning to attend college. The nurse should inform the client that he should receive which of the following immunizations prior to moving into a campus dormitory? A. Pneumococcal polysaccharide B. Meningococcal polysaccharide C. Rotavirus D. Herpes zoster
B. Meningococcal polysaccharide Rationale: College freshmen, particularly those who live in dormitories, are at an increased risk for meningococcal disease relative to other persons their age. Therefore, the Centers for Disease Control and Prevention has issued a recommendation that all incoming college students receive the meningococcal immunization.
A nurse in a pediatric clinic is assessing a toddler at a well-child visit. Which of the following actions should the nurse take? A. Perform the assessment in a head to toe sequence B. Minimize physical contact with the child initially C. Explain procedures using medical terminology D. Stop the assessment if the child becomes uncooperative
B. Minimize physical contact with the child initially Rationale: The nurse should initially minimize physical contact with the toddler, and then progress from the least traumatic to the most traumatic procedures.
A nurse is creating a plan of care for a child who has leukopenia secondary to chemotherapy. Which of the following interventions should the nurse include in the plan? A. Maintain the child on bed rest. B. Monitor the child for increased temperature. C. Administer oxygen to the child. D. Monitor the child for bleeding.
B. Monitor the child for increased temperature. Rationale: Leukopenia places the child at risk for infection; therefore, the nurse should monitor the child for a fever.
A nurse is assessing a child who has a ventricular septal defect. Which of the following findings should the nurse expect? A. Diastolic murmur B. Murmur at the left sternal border C. Cyanosis that increases with crying D. Widened pulse pressure
B. Murmur at the left sternal border Rationale: A ventricular septal defect, a hole in the septal wall between the ventricles, is an acyanotic heart defect. A systolic murmur can be best heard at the lower left sternal border. Sound is transmitted in the direction of blood flow, so any back flow of blood from the left to the right ventricle through the septal defect is best heard in this area.
A school nurse is assessing a child who has been stung by a bee. The child's hand is swelling and the nurse notes that the child has allergies to insect stings. Which of the following findings should the nurse expect if the child develops anaphylaxis? (Select all that apply.) A. Bradycardia B. Nausea C. Hypertension D. Urticaria E. Stridor
B. Nausea D. Urticaria E. Stridor Rationale: Vausea is correct. A common gastrointestinal response to excessive histamine release is nausea. Urticaria is correct. A common skin manifestation of excessive histamine release is hives, also known as urticaria. Stridor is correct. A serious, life-threatening response to excessive histamine release is airway narrowing, which presents as dyspnea and stridor.
A nurse on a pediatric unit is admitting a 4-year-old child. Which of the following toys should the nurse plan to provide for the child to engage in independent play? A. Brightly colored mobile B. Plastic stethoscope C. Small piece jigsaw puzzle D. A book of short stories
B. Plastic stethoscope Rationale: Preschool play centers on imitative activities. Providing a stethoscope allows the child an opportunity for therapeutic play. Imitating health care personnel helps to ease the fear of unfamiliar equipment.
A nurse is reviewing the laboratory report of a 2-year-old child who has diarrhea and has been vomiting for 24 hr. Which of the following findings should the nurse report to the provider? A. Hct 40% B. Potassium 2.5 mEg/L C. Serum creatinine 0.4 mg/dL D. BUN 6 mg/dL
B. Potassium 2.5 mEg/L
A nurse is caring for a 6-week-old infant following a pyloromyotomy. Which of the following forms of feeding should the nurse anticipate for the infant 6 hr after the procedure? A. Bottle formula with added protein B. Small, frequent bottle feedings of electrolyte solution C. Continuous nasoduodenal tube feedings D. Bolus feedings via gastrostomy tube
B. Small, frequent bottle feedings of electrolyte solution Rationale: Feedings begin 4 to 6 hr after the surgical procedure. The nurse should anticipate feeding the infant small, frequent increments of an electrolyte solution or sterile water.
A nurse is caring for an infant following surgical repair of a cleft lip and palate. Which of the following actions should the nurse take? A. Keep the infant's mouth open by using a tongue blade for 4 hr following surgery. B. Use a suction catheter to gently remove the infant's oral secretions PRN. C. Place the infant in prone position. D. Clean the infant's incision with chlorhexidine.
B. Use a suction catheter to gently remove the infant's oral secretions PRN. Rationale: The nurse should use a suction catheter to gently remove the infant's oral secretions to prevent aspiration and maintain a patent airway.
A nurse is assessing a 3-year-old child who is 1 day postoperative following a tonsillectomy. Which of the following methods should the nurse use to determine if the child is experiencing pain? A. Ask the parents. B. Use the FACES scale. C. Use the numeric rating scale. D. Check the child's temperature.
B. Use the FACES scale. Rationale: Pain is a subjective experience even for a 3-year-old child. The FACES scale can be used to accurately determine the presence of pain in children as young as 3 years of age.
A nurse in the emergency department is caring for a 12-year-old child who has ingested bleach. Which of the following statements by the nurse indicates an understanding of this ingestion? A. "The absence of oral burns excludes the possibility of esophageal burns." B. "Treatment focuses on neutralization of the chemical." C. "'Injury by a corrosive liquid is more extensive than by a corrosive solid." D. "Immediate administration of activated charcoal is warranted."
C. "'Injury by a corrosive liquid is more extensive than by a corrosive solid." Rationale: The coating action of liquids permits larger areas of contact with tissues and results in more extensive Injury.
A nurse is teaching a parent of an infant who has a colostomy. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will not dress my child in one-piece outfits." B. "I need to buy diapers that are tighter than my infant usually wears." C. "I need to apply paste to the back of the wafer on my child's appliance." D. "I will not need to toilet train my child."
C. "I need to apply paste to the back of the wafer on my child's appliance." Rationale: The parent should apply stoma paste to the back of the wafer on the appliance, as well as around the stoma, to act as a sealant to prevent skin breakdown.
A nurse is providing postoperative teaching for the parent of a 3-month-old infant who is recovering from an umbilical hernia repair. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will expect the site to bulge when my baby cries." B. "I will place a belly band around my child's abdomen." C. "I will fold my baby's diaper away from the incision." D. "I will bathe my child in the bath tub daily."
C. "I will fold my baby's diaper away from the incision."
A nurse is providing education to the parent of a toddler who is about to receive an MMR (measles, mumps and rubella) immunization. Which of the following statements by the parent indicates an understanding of the teaching? A. "My child should not play with other children for 2 days." B. " I will need to return in 2 weeks for my child to receive the varicella immunization." C. "I will help my child to blow bubbles during the injection." D. "My child may have some drainage from the injection site."
C. "I will help my child to blow bubbles during the injection." Rationale: Providing distraction, such as helping or allowing a child to blow bubbles while receiving an injection, is a technique that can minimize pain and discomfort for the child.
A nurse is providing discharge teaching to the parent of a school-age child who has leukemia and is receiving chemotherapy. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will take my child's rectal temperature daily." B. "I will make sure my child gets his MMR vaccine this week." C. "I will inspect my child's mouth every day for sores." D. "I will allow my child to ride his bicycle tomorrow."
C. "I will inspect my child's mouth every day for sores." Rationale: A child who has leukemia is at an increased risk for mucositis; therefore, the parent should inspect the child's mouth daily for lesions or ulcerations.
A nurse is teaching the parents of a child who has cerebral palsy. Which of the following statements should the nurse make? A. "Your child will be unable to eat by mouth." B. "Your child will be unable to participate in recreational activities." C. "Your child will need a botulinum toxin A injection to help with muscle spasticity. D. "Your child will need throw rugs placed over non-carpeted areas."
C. "Your child will need a botulinum toxin A injection to help with muscle spasticity. Rationale: Children who have cerebral palsy have spasticity in their muscles. The child can receive botulinum toxin type A injections into affected muscles, which aid in reducing the spasticity.
A nurse is caring for a child who has epistaxis. Which of the following actions should the nurse take? A. Apply a warm cloth to the bridge of the child's nose. B. Tilt the child's head back. C. Apply continuous pressure to the child's nose for at least 10 min. D. Administer aspirin for the child's pain.
C. Apply continuous pressure to the child's nose for at least 10 min.
A nurse is assessing a 6-month-old infant following a cardiac catheterization. Which of the following findings should the nurse report to the provider? A. Temperature of 37.5° C (99.5° F) B. Apical pulse rate 140/min C. BP 86/40 mm Hg D. Respiratory rate of 32/min
C. BP 86/40 mm Hg Rationale: A BP of 86/40 mm Hg is indicative of hypotension and bleeding in a 6-month-old infant and should be immediately reported to the provider.
A nurse is teaching about clinical manifestations of tracheomalacia to a parent of an infant who had tracheoesophageal fistula repair as a newborn. Which of the following findings should the nurse include in the teaching? A. Absence of bowel sounds B. Neck contortions C. Barking cough D. Projectile vomiting
C. Barking cough Rationale: Infants who have tracheomalacia have a weakened trachea, which leads to collapse. Clinical manifestations of tracheomalacia include barking cough, stridor, wheezing cyanosis, and apnea.
A nurse is assessing a 30-month-old toddler during a well-child visit. Which of the following findings requires further assessment by the nurse? A. Primary dentition is complete B. Unable to hop on one foot C. Birth weight is tripled D. Able to state first and last name
C. Birth weight is tripled Rationale: The birth weight should triple by 12 months of age. By 30 months of age, the birth weight should be quadrupled.
A nurse is providing anticipatory guidance about accidental ingestion of a toxic substance to the parents of a toddler. The nurse should instruct the parents to take which of the following actions first if the child ingests a hazardous substance? A. Give the toddler milk. B. Go to an emergency department. C. Call the poison control center. D. Induce vomiting.
C. Call the poison control center. Rationale: According to evidence-based practice, the nurse should instruct the parents to first call the poison control center, which will then identify what further actions the parents should take.
A nurse in an emergency department is caring for a toddler who is in acute respiratory distress. Which of the following findings should alert the nurse to the possibility of epiglottitis? A. Lethargy B. Spontaneous coughing C. Drooling D. Hoarseness
C. Drooling Rationale: Epiglottitis is a disorder caused by an inflammation of the epiglottis. It results in rapid swelling of the epiglottis, which can obstruct breathing. Drooling is common finding due to the toddler's inability to swallow saliva.
A nurse is caring for an 8-year-old child who has sickle cell anemia. Which of the following actions should the nurse take? A. Apply cool compresses to the painful area. B. Initiate contact isolation precautions. C. Give the child flavored popsicles. D.V Administer phytonadione.
C. Give the child flavored popsicles. Rationale: Maintaining hydration with a child who has sickle cell anemia is important to prevent sickling. Children accept flavored popsicles as a source of fluid.
A nurse is preparing to administer recommended highlight immunizations to a 2-month-old infant. Which of the following immunizations should the nurse plan to administer? A. Human papillomavirus (HPV) and hepatitis A B. Measles, mumps, rubella (MMR) and tetanus, diphtheria, and acellular pertussis (TaP) C. Haemophilus influenzae type B (Hib) and inactivated polio virus (IPV) D. Varicella (VAR) and live attenuated influenza vaccine (LAI)
C. Haemophilus influenzae type B (Hib) and inactivated polio virus (IPV) Rationale: The recommended immunizations for a 2-month-old infant include Hib and IPV. The Hib immunization series consists of 3 to 4 doses, depending on the immunization used, and at a minimum is administered at the ages of 2 months, 4 months, and 12 to 15 months. The IPV immunization series consists of 4 doses and is administered at the ages of 2 months, 4 months, 6 to 18 months, and 4 to 6 years.
A nurse is assessing a 6-month-old infant at a well-child visit. Which of the following findings indicates the need for further assessment? A. Grabs feet and pulls them to her mouth B. Posterior fontanel is closed C. Legs remain crossed and extended when supine D. Birth weight has doubled
C. Legs remain crossed and extended when supine Rationale: Legs crossed and extended when supine is an unexpected finding and requires further assessment. At 6 months of age, the legs flex at the knees when the infant is supine. Crossed and extended legs when supine is a finding associated with cerebral palsy.
A nurse is planning care for an adolescent who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions should the nurse include in the plan? A. Apply cold compresses to the child's extremities. B. Administer meperidine every 4 hr until the crisis has resolved. C. Maintain the child on bed rest. D. Decrease the child's fluid intake for 8 hr.
C. Maintain the child on bed rest. Rationale: The nurse should maintain bed rest for the child who is experiencing a vaso-occlusive crisis to minimize energy expenditure and avoid additional oxygen needs.
A nurse is observing a mother who is playing peek-a-boo with her 8. month-old child. The mother asks if this game has any developmental significance. The nurse should inform the mother that peek-a-boo helps develop which of the following concepts in the child? A. Hand-eye coordination B. Sense of trust C. Object permanence D. Egocentrism
C. Object permanence Rationale: Object permanence refers to the cognitive skill of knowing an object still exists even when it is out of sight. In discovering a hidden object while playing peek-a-boo, the infant experiences validation of this concept.
A nurse is teaching the parent of an infant about home safety. Which of the following information should the nurse include? (Select all that apply.) A. Use a wheeled infant walker. B. Place soft pillows around the edge of the infant's crib. C. Position the car seat so it is rear-facing. D. Secure a safety gate at the top and bottom of the stairs. E. Maintain the water heater temperature at 49° C (120° F).
C. Position the car seat so it is rear-facing. D. Secure a safety gate at the top and bottom of the stairs. E. Maintain the water heater temperature at 49° C (120° F). Rationale: Positioning the car seat so it is rear-facing is correct. Infants and children should remain in the rear-facing position when in a car seat until the age of 2 years or until they reach the recommended height and weight per the manufacturer's guidelines. Securing a safety gate at the top and bottom of the stairs is correct. As the infant begins to crawl and becomes more mobile, the risk of falls increases. Maintaining the water heater temperature at 49° C (120° F) is correct. To prevent a burn injury, the temperature of the water heater should not exceed 49° C (120° F).
A nurse is admitting a child who has Wilms' tumor. Which of the following actions should the nurse take? A. Initiate contact precautions for the child. B. Explain to the parents that chemotherapy will start 3 months following surgery. C. Put a "no abdominal palpation" sign over the child's bed. D. Prepare the child for a spinal tap.
C. Put a "no abdominal palpation" sign over the child's bed. Rationale: The nurse should place a sign over the child's bed reading "no abdominal palpation" because palpation is not necessary to confirm diagnosis and could aid in metastasis.
A nurse is providing nutritional teaching to an adolescent client who has celiac disease. Which of the following breakfast foods should the nurse recommend? A. Plain flour pastry B. Wheat cereal C. Scrambled eggs D. Rye toast
C. Scrambled eggs
A nurse is assessing a 6-month-old infant who was recently admitted with acute vomiting and diarrhea. Which of the following findings indicates the infant has moderate dehydration? A. Bulging anterior fontanel B. Bradycardia C. Tachypnea D. Polyuria
C. Tachypnea Rationale: An infant who has moderate dehydration will have a slight tachypnea.
A nurse is assessing a 7-year-old child's psychosocial development. Which of the following findings should the nurse recognize as requiring further evaluation? A. The child prefers playmates of the same sex. B. The child is competitive when playing board games. C. The child complains daily about going to school. D. The child enjoys spending time alone.
C. The child complains daily about going to school. Rationale: Complaining every day about going to school is an unexpected finding for a 7-year-old child. The child is in Erikson's psychosocial development stage of industry vs. inferiority. Children in this stage want to learn and master new concepts. If the child complains daily about going to school, it warrants further evaluation.
A nurse is caring for a 15-month-old toddler who requires droplet precautions. Which of the following actions should the nurse take? A. Have the toddler wear a disposable gown when in the unit's playroom. B. Wear sterile gloves when changing the toddler's diapers. C. Wear a mask when assisting the toddler with meals. D. Ask visitors to wear an N-95 mask when entering the room.
C. Wear a mask when assisting the toddler with meals. Rationale: The nurse should wear a mask when within 3 to 6 feet of the toddler to prevent the transmission of infections that are spread via large droplet particles expelled in the air.
A nurse is teaching a parent of a 12-month-old infant about development during the toddler years. Which of the following statements should the nurse include? A. "Your child should be referring to himself using the appropriate pronoun by 18 months of age." B. "A toddler's interest in looking at pictures occurs at 20 months of age." C. "A toddler should have daytime control of his bowel and bladder by 24 months of age." D. "Your child should be able to scribble spontaneously using a crayon at the age of 15 months."
D. "Your child should be able to scribble spontaneously using a crayon at the age of 15 months." Rationale: The nurse should teach the parent that at the age of 15 months, the toddler should be able to scribble spontaneously, and at the age of 18 months, the toddler should be able to make strokes imitatively.
A clinic nurse is providing teaching to the parent of a 1-month-old infant who has gastroesophageal reflux. Which of the following statements by the parent indicates an understanding of the teaching? A. " I will give the lansoprazole 30 min after my baby's feedings." B. "I will lay my baby on her side after feedings." C. "I will give my baby a bottle just before bedtime." D. "I will add rice cereal to my baby's feedings."
D. "I will add rice cereal to my baby's feedings." Rationale: The mother should add 1 tsp to 1 tbsp of rice cereal per ounce of formula or expressed breast milk to thicken the feedings because this will decrease the number of vomiting episodes.
A nurse is teaching a school-age child who is to undergo a bone marrow aspiration. Which of the following statements should the nurse make? A. " I will give you an antibiotic before your procedure." B. "I will place you on your side during the procedure." C. "You might have a headache following the procedure." D. "I will place a pressure dressing over the area following the procedure."
D. "I will place a pressure dressing over the area following the procedure." Rationale: Dressing helps prevent bleeding from the site
A nurse is teaching an adolescent who has asthma about how to use a peak expiratory flow meter (PEFM). Which of the following responses by the adolescent indicates an understanding of the teaching? A. "I will breathe in through the mouthpiece, hold my breath for 5 seconds, and then exhale." B. "If l get a reading in the green zone, I will tell my parents immediately so they can call the doctor." C. "I will slowly exhale through the mouthpiece over a 10 second interval." D. "I will record the highest reading of three attempts."
D. "I will record the highest reading of three attempts." Rationale: Once the client establishes a personal best, she should routinely check the PEFM by performing three attempts and recording the highest reading of the three.
A nurse is teaching the parent of a 12-month-old infant about nutrition. Which of the following statements by the parent indicates a need for further teaching? A. "I can give my baby A ounces of juice to drink each day." B. "I will offer my baby dry cereal and chilled banana slices as snacks." C. "I am introducing my baby to the same foods the family eats." D. "My infant drinks at least 2 quarts of skim milk each day."
D. "My infant drinks at least 2 quarts of skim milk each day." Rationale: As the infant transitions into toddlerhood, whole milk intake should average 24 to 30 oz per day. Too much milk can affect intake of solid foods and result in iron deficiency anemia. Skim milk is not recommended until after age 2 since it lacks essential fatty acids which are needed for growth and development.
A nurse is preparing to obtain an antistreptolysin O (ASO) titer from a child who has acute glomerulonephritis. The child's parent asks the nurse to explain the purpose of the test. Which of the following responses should the nurse make? A. "The test determines the level of antibiotics in your child's blood." B. "The test tells us if your child ever had the measles." C. "The test verifies the amount of albumin in your child's blood." D. "The test shows us if your child had a recent strep infection."
D. "The test shows us if your child had a recent strep infection." Rationale: An ASO titer indicates that the child has had a recent strep infection. In determining a definitive diagnosis for acute glomerulonephritis, this must be documented as it is usually the result of this type of infection.
A nurse is teaching the parents of an infant who has congenital hypothyroidism. Which of the following statements should the nurse make? A. "Your child will need to take estrogen daily when she reaches puberty." B. "Your child will need monthly blood coagulation studies." C. "Your child will need surgery to remove the diseased thyroid." D. "Your child will need to take thyroid hormone replacement for her entire life."
D. "Your child will need to take thyroid hormone replacement for her entire life." Rationale: In congenital hypothyroidism, the child does not manufacture an adequate amount of thyroid hormone to maintain the appropriate metabolic rate. The child will require life-long thyroid hormonal replacement for normal growth and development.
A nurse is caring for a child who adheres to a vegetarian diet and has sustained superficial partial-thickness burns. The nurse should recommend which of the following food choices as having the highest protein content? A. Medium baked potato B. Wheat bagel with 1 tbsp of apricot jam C. Large orange D. 1/2 cup of peanut butter with apple slices
D. 1/2 cup of peanut butter with apple slices Rationale: Peanut butter and apple slices have a total of 28.91 g of protein. This is a good choice for this client because peanut butter is high in protein, which helps with the healing process.
A nurse in an emergency department is caring for an 8-year old who is up-to-date with current immunization recommendations and has a deep puncture injury. Which of the following should the nurse anticipate administering? A. Diphtheria, tetanus, and acellular pertussis (DTa) vaccine A. A single injection of tetanus immune globulin (TIC) mixed with the pediatric tetanus booster (DT) C. Tetanus, diphtheria, and acellular pertussis (Tap) vaccine D. Adult tetanus booster (Td)
D. Adult tetanus booster (Td) Rationale: Td is recommended for wound prophylaxis in children ages 7 years and older. Td is also recommended every 10 years after 18 years of age.
A nurse is caring for a 2-year-old child who has cystic fibrosis. The nurse is planning to take the child to the playroom. Which of the following activities would be appropriate for the child? A. Cutting figures from colored paper B. Drawing stick figures using crayons C. Riding a tricycle D. Building towers of blocks
D. Building towers of blocks Rationale: Building towers of blocks is an appropriate activity for a 2-year-old child. It promotes fine-motor development, and knocking blocks down provides a means of dealing with the stress of hospitalization.
A nurse is caring for a 12-month-old infant following surgical repair of a cleft palate. The nurse should plan to feed the infant using which of the following instruments? A. Spoon B. Straw C. Firm nipple D. Cup
D. Cup Rationale: The infant should be fed clear liquids using a cup for 7 to 10 days following a cleft palate repair to prevent trauma and injury to the suture line.
A nurse is teaching a school-age child and his parents how to self-administer insulin. Which of the following actions should the nurse take first? A. Allow a parent to administer an injection to the nurse. B. Have the child teach the injection technique to the parents. C. Have a parent administer the insulin injection to the child. D. Demonstrate the injection technique on an orange.
D. Demonstrate the injection technique on an orange.
A nurse in an emergency department is caring for a 4-year-old child who has burns to the neck and face following a house fire. Which of the following actions should the nurse take first? A. Cover the child's wounds with a clean, dry cloth. B. Establish IV access for the child with a large-bore catheter. C. Provide reassurance to the child's parents. D. Determine the child's breathing pattern.
D. Determine the child's breathing pattern. Rationale: ABCs
A nurse is caring for a child who is in skeletal traction. Which of the following actions is the nurse's priority? A. Perform passive range of motion for unaffected joints. B. Apply a pressure-reducing overlay to the child's mattress. C. Increase the child's fluid intake. D. Encourage the child to use an incentive spirometer.
D. Encourage the child to use an incentive spirometer. Rationale: ABCs
A nurse in a pediatric clinic is caring for a 3-year-old child who has a bl lead level of 3 mcg/dL. When teaching the toddler's parent about the correlation of nutrition with lead poisoning, which of the following information is appropriate for the nurse to include in the teaching? A. Decrease the child's vitamin C intake until the blood lead level decreases to zero B. Administer a folic acid supplement to the child each day. C. Give pancreatic enzymes to the child with meals and snacks. D. Ensure the child's dietary intake of calcium and iron is adequate.
D. Ensure the child's dietary intake of calcium and iron is adequate. Rationale: A child who has an elevated blood lead level should have an adequate intake of calcium and iron to reduce the absorption and effects of the lead. Dietary recommendations should include milk as a good source of calcium.
A nurse is caring for a child who has cystic fibrosis and a pulmonary infection. Which of the following findings is the nurse's priority? A. Blood streaking of the sputum B. Dry mucous membranes C. Constipation D. Inability to clear secretions
D. Inability to clear secretions Rationale: ABCs. Therefore, the inability to clear secretions is the priority-finding because the child has a compromised airway and the nurse must act in a manner that ensures transportation of oxygen to the body's cells.
A nurse is providing discharge teaching to the parents of a child who has nephrotic syndrome. Which of the following instructions should the nurse include in the teaching? A. Restrict the child's potassium intake. B. Administer acetaminophen to the child twice daily. C. Weigh the child once each week. D. Keep the child away from people who have an infection.
D. Keep the child away from people who have an infection. Rationale: Children who have nephrotic syndrome are at increased risk for infection and should avoid contact with people who have infections.
A nurse is caring for an 8-year-old child who has acute glomerulonephritis. Which of the following findings should the nurse expect? A. Hypotension B. Stomatitis C. Bloody diarrhea D. Periorbital edema
D. Periorbital edema Rationale: Periorbital edema is an expected finding in a child who has glomerulonephritis.
A nurse is caring for an adolescent who is receiving pain medication via a PCA pump. When the nurse assesses the client's pain at 0800, the client describes the pain as a 3 on a scale of 1 to 10. At 1000, the client describes the pain as a 5. The nurse discovers the client has not pushed the button to deliver medication in the past 2 hr. Which of the following actions should the nurse take? A. Ask the provider to discontinue the PC so the nurse can administer PRN pain medication. B. Suggest the client's parent push the button for the client if the parent thinks the adolescent is having pain. C. Reevaluate the client in 1 hr since a pain level of 5 is acceptable on a scale of 1 to 10. D. Reinforce teaching with the client about how to push the button to deliver the medication.
D. Reinforce teaching with the client about how to push the button to deliver the medication. Rationale: The appropriate action at this time is to reinforce client teaching about the PCA. The nurse should remind the client about the availability of the medication, verify that the client knows how to use the equipment, and emphasize the importance of using it regularly to manage pain effectively.
A nurse is planning to implement relaxation strategies with a young child prior to a painful procedure. Which of the following actions should the nurse take? A. Ask the child to hold his breath and then blow it out slowly B. Ask the child to describe a pleasurable event C. Bounce the child gently while holding him upright D. Rock the child in long rhythmic movements
D. Rock the child in long rhythmic movements Rationale: The nurse can implement relaxation strategies by sitting with the child in a well-supported position such as against the chest, and then rocking or swaying back and forth in long, wide movements
A nurse is caring for a child who has suspected nephrotic syndrome. Which of the following laboratory values should the nurse expect? A. Platelet count 120,000/mm B. Serum sodium 160 mEq/L C. Hgb 9 g/dL D. Serum cholesterol 700 mg/dL
D. Serum cholesterol 700 mg/dL Rationale: A serum cholesterol level of 700 mg/dL is above the expected reference range. A child who has nephrotic syndrome will have high serum cholesterol findings because of the increase in plasma lipids.
A nurse in an emergency department is assessing a school-age child who is experiencing an acute asthma exacerbation. Which of the following findings is the priority for the nurse to report to the provider? A. Excessively prolonged expiration B. Increased diaphoresis C. Increased production of frothy sputum D. Sudden decrease in wheezing
D. Sudden decrease in wheezing Rationale: A sudden decrease in wheezing can be an indication that the child is experiencing decreased air movement and should be reported to the provider. The nurse might also need to use Maslow's hierarchy of needs, the ABC priority setting framework, or nursing knowledge to identify which finding is the most urgent. A sudden decrease in wheezing (silent chest) indicates ventilator failure and an imminent respiratory arrest.
A nurse is assisting a provider during a femoral venipuncture on a toddler. The nurse should place the child in which of the following positions? A. Side-lying B. Semi-recumbent C. Flexed sitting D. Supine
D. Supine Rationale: The client is placed in the supine position, with the client's legs in a frog position.
A nurse is caring for a child who has a vesicular rash. The parents of the child asks the nurse what illness can cause this rash for 6 days. The nurse should expect that the child has which of the following conditions? A. Measles B. Fifth disease C. Tetanus D. Varicella
D. Varicella Rationale: Children who have varicella might commence with a maculopapular rash that progresses to vesicles on erythematous bases that eventually rupture and crust over.
