ATI PN Nursing Care of Children 2020 Practice A

A nurse is monitoring a child who is receiving a transfusion of packed RBCs. Which of the following responses by the child is an indication of a transfusion reaction? a. "I am cold. Can I have an extra blanket?" b. "My nose is runny. Can I have a tissue?" c. "I am sleepy. I might take a nap after this." d. "I am hungry. Can I get a snack?"

"I am cold. Can I have an extra blanket?" Rationale: The nurse should identify that being cold and having chills is an indication of a transfusion reaction.

A nurse is reinforcing discharge teaching with the guardian of a child who has juvenile idiopathic arthritis (JIA). Which of the following statements by the guardian indicates an understanding of the teaching? a. "I will apply topical hydrocortisone to my child's joints as needed." b. "I will have my child sleep in knee, wrist, and hand splints." c. "I will encourage my child to take an afternoon nap." d. "I will administer opioids to my child for the next several months to control the pain."

"I will have my child sleep in knee, wrist, and hand splints." Rationale: The nurse should reinforce with the guardian that splinting the child's joints at night will decrease pain and enhance joint function.

A nurse is assisting with a sterile dressing change for an adolescent who has a partial thickness burn on the right hip. Which of following actions should the nurse take first? a. Open the sterile dressing tray. b. Administer pain medication to the client. c. Assist the client into the left lateral position. d. Remove the previous dressing to inspect the wound.

Administer pain medication to the client. Rationale: According to evidence-based practice, the nurse should first provide pain medication to the client to reduce discomfort during the procedure.

A nurse is reinforcing dietary teaching about a low-sodium diet with the parents of a child who is recovering from acute glomerulonephritis. Which of the following food choices by the parents indicates an understanding of the teaching? a. Apples b. Canned corn c. Pretzels d. Peanut butter

Apples Rationale: The nurse should instruct the parents that apples are low in sodium and supply the child with energy needed for recovery.

A nurse is preparing to administer ophthalmic drops to a child. Which of the following actions should the nurse take? a. Apply pressure to the lacrimal punctum for 1 min following administration. b. Position the child with his head flexed while administering the medication. c. Hold the dropper 5 cm (2 in) above the eye to administer the medication. d. Wipe the excess medication toward the inner canthus with a cotton swab.

Apply pressure to the lacrimal punctum for 1 min following administration. Rationale: The nurse should apply pressure to the lacrimal punctum to prevent the medication from entering the nasopharynx.

A nurse is collecting data from a 12-month-old infant during a well-child visit. Which of the following findings should the nurse report to the provider? a. Temperature 37.5° C (99.5° F) b. Respiratory rate 30/min c. Heart rate 130/min d. BP 115/70 mm Hg

BP 115/70 mm Hg Rationale: The nurse should identify that this blood pressure is above the expected reference range for a 12-month-old infant and report this finding to the provider.

A nurse is assisting with scoliosis screenings for a group of school-age children. The nurse should place the students in which of the following positions during the screening? a. Standing with feet shoulder-width apart b. Bending forward with back parallel to the floor c. Bending knees while placing hands on hips d. Clasping hands while arms are raised above the head

Bending forward with back parallel to the floor Rationale: The nurse should observe for asymmetry and prominence of the rib cage by having the students bend forward with the back parallel to the floor.

A nurse is preparing to administer an enteral feeding to a child who has cerebral palsy and a nasogastric tube. Which of the following actions should the nurse take? a. Refrigerate the formula for 30 min prior to administration. b. Administer 20 mL/min of formula by gravity. c. Flush the tube with 5 to 15 mL of 0.9% sodium chloride. d. Confirm that the pH of the stomach contents is 5 or less.

Confirm that the pH of the stomach contents is 5 or less. Rationale: The nurse should test the pH of the stomach contents prior to administering the tube feeding in order to confirm tube placement in the stomach. The nurse should identify that a pH of 5 or less indicates gastric placement.

A nurse is reviewing the medical record of a female adolescent client who has primary amenorrhea. Which of the following findings should the nurse identify as a risk factor for this disorder? (Select all that apply.) a. Cannabis use b. Obesity c. Hypothyroidism d. Oral contraceptive use e. Emotional stress

Hypothyroidism, Cannabis use, Oral contraceptive use, Emotional stress Rationale: The nurse should identify that hypothyroidism and other endocrine disorders are risk factors for primary amenorrhea. The nurse should identify that cannabis use is a risk factor for primary amenorrhea. The nurse should identify that oral contraceptive use affects the estrogen and progesterone cycle and is a risk factor for primary amenorrhea. The nurse should identify that emotional stress causes hypothalamic suppression and is a risk factor for primary amenorrhea.

A nurse is caring for a child who has a head injury following a motor vehicle crash. Which of the following should the nurse recognize as an early manifestation of increased intracranial pressure? a. Decorticate posturing b. Increased irritability c. Cheyne-Stokes respirations d. Fixed and dilated pupils

Increased irritability Rationale: The nurse should recognize that increased irritability, fatigue, vomiting, and headache are early signs of increased intracranial pressure.

A nurse is contributing to the plan of care for an adolescent client who has human immunodeficiency virus (HIV). Based on the adolescent's diagnosis, which of the following actions should be included in the plan of care? a. Contact the dietary department to request that foods be delivered on disposable dishes. b. Instruct visitors to wear gowns and masks when entering the client's room. c. Inform the client regarding routes of transmission. d. Prepare a negative-pressure airflow room for the client.

Inform the client regarding routes of transmission. Rationale: The nurse should inform the client about the transmission of HIV and how to prevent its spread.

A nurse is collecting data from a toddler at a well-child visit. Which of the following findings should the nurse identify as a possible indication of child maltreatment? a. Inflamed unilateral conjunctiva b. Diaper dermatitis c. Laceration on the side of the torso d. Bruise on the front of the lower leg

Laceration on the side of the torso Rationale: A laceration on the side of the torso is not an injury that occurs due to the typical clumsiness of a toddler. This finding indicates the need to further investigate for suspected child maltreatment.

A nurse is reviewing the laboratory report of a preschooler. Which of the following laboratory results should the nurse report to the provider? a. Potassium 4.2 mEq/L b. Lead 14 mcg/dL c. Fasting blood glucose 75 mg/dL d. Hematocrit 40%

Lead 14 mcg/dL Rationale: This lead level is above the expected reference range for a preschooler. Therefore, the nurse should report this result to the provider.

A nurse is contributing to the plan of care for a child who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following is the priority intervention for the nurse to recommend to include in the plan? a. Administer antibiotics. b. Encourage fluid intake. c. Apply a warm compress to the joints. d. Promote oxygen utilization.

Promote oxygen utilization. Rationale: The priority action the nurse should take when using the airway, breathing, circulation (ABC) approach to client care is promoting oxygen utilization to prevent further sickling of the red blood cells and promote adequate oxygenation of the tissue.

A nurse is caring for a school-age child who has skeletal traction applied to the right lower leg to repair a femur fracture. Which of the following findings is the priority for the nurse to report to the provider? a. Pain rating of 7 on a scale of 0 to 10 b. Report of tingling in the right foot c. Increase in crusting at pin sites d. Decrease in food intake

Report of tingling in the right foot Rationale: The nurse should identify that the greatest risk to the child is nerve injury. Therefore, tingling in the right foot, which can indicate nerve damage or compartment syndrome, is the priority finding for the nurse to report to the provider.

A nurse is collecting data from an adolescent who has manifestations of physical abuse. Which of the following actions should the nurse take? a. Conduct the admission process with the adolescent's parent at bedside. b. Use closed-ended questioning when speaking with the adolescent. c. Encourage the adolescent to enroll in family psychotherapy. d. Report the suspected abuse to the authorities.

Report the suspected abuse to the authorities. Rationale: Nurses are required mandatory reporters of child abuse. It is the nurse's responsibility to report any type of abuse to the appropriate agencies. This action will assist with ensuring a safe environment for the adolescent.

A nurse is reinforcing teaching with the guardian of a child who has a new diagnosis of enterobiasis. The nurse should advise the guardian to take which of the following actions to prevent infection? a. Dress the child in two-piece sleeping outfits. b. Trim the child's fingernails short. c. Have the child take a tub bath daily. d. Repeat treatment in 4 weeks.

Trim the child's fingernails short. Rationale: The nurse should instruct the guardian to trim the child's fingernails short to reduce the collection of eggs under their nails and prevent reinfection.

A nurse is reinforcing teaching with the guardian of an infant who has Down syndrome. Which of the following instructions should the nurse include to decrease the child's risk of an upper respiratory infection? a. Limit the infant's fluid intake. b. Use a cool mist vaporizer in the infant's room. c. Rinse the infant's mouth with water before feeding. d. Avoid applying lip balm to the infant's lips.

Use a cool mist vaporizer in the infant's room. Rationale: The nurse should reinforce that a cool mist vaporizer should be used to help thin respiratory secretions and decrease the infant's risk for an upper respiratory infection.

A nurse is reinforcing teaching with the guardians of a school-age child who has hearing loss. Which of the following techniques should the nurse recommend to facilitate communication with the child? a. Keep hands still when speaking. b. Stand away from child when speaking. c. Use facial expressions when speaking. d. Exaggerate the pronunciation of each word.

Use facial expressions when speaking. Rationale: The nurse should instruct the guardians to use facial expressions when speaking to assist in conveying the message being spoken.

A nurse is collecting data from a child who has iron deficiency anemia. Which of the following data signifies that adherence to ferrous sulfate therapy has occurred? a. Green, tarry stools b. Occasional vomiting and nausea c. Weight gain d. Tolerates milk

Green, tarry stools Rationale: Green, tarry stools are an expected outcome of ferrous sulfate therapy. Therefore, this is an indication of adherence to the prescribed medication regimen.

A nurse is caring for an adolescent client who is experiencing sickle cell crisis. Which of the following laboratory values should the nurse report to the provider? a. Total bilirubin 0.5 mg/dL b. Hgb 6 g/dL c. WBC count 8,000/mm3 d. Reticulocyte count 1%

Hgb 6 g/dL Rationale: The expected reference range for an adolescent's Hgb level is 10 to 15.5 g/dL. Therefore, an Hgb of 6 g/dL is below the expected reference range and should be reported to the provider.

A nurse is caring for a child who has a fractured tibia and is in Buck's traction. Which of the following actions should the nurse take? a. Use palms of hands when handling the traction boot. b. Allow the child to change positions frequently. c. Ensure the weights are hanging freely. d. Check the pin site every 8 hr.

Ensure the weights are hanging freely. Rationale: The nurse should ensure that the weights are hanging freely for a child who is in Buck's traction.

A nurse is caring for a school-age female who is being treated for frequent, severe urinary tract infections (UTIs). The nurse should recognize that which of the following statements by the parent indicates a possible cause of the UTIs? a. "She urinates every 2 to 3 hours during the day." b. "My daughter has bowel movements every 4 to 5 days." c. "I taught her to wipe from front to back after going to the bathroom." d. "I don't let her wear nylon underwear."

"My daughter has bowel movements every 4 to 5 days." Rationale: The nurse should recognize that this frequency indicates the child is constipated. Therefore, large stool masses might prevent complete emptying of the bladder and lead to urinary stasis and infection.

A nurse is reviewing the laboratory report of a preschooler who has a Wilms' tumor and is scheduled to begin treatment with an antineoplastic medication regimen. Which of the following laboratory results should the nurse report to the provider? a. Platelet count 70,000/mm3 b. Serum glucose 98 mg/dL c. WBC count 5,500/mm3 d. BUN 16 mg/dL

Platelet count 70,000/mm3 Rationale: This platelet count is below the expected reference range for a preschooler and increases the risk for spontaneous bleeding. The nurse should hold the medication and report this finding to the provider immediately.

A nurse is reinforcing discharge teaching with the guardian of a school-age child who has a new prescription for home oxygen therapy. Which of the following statements by the guardian indicates an understanding of the teaching? a. "I will place the extra oxygen tanks in a horizontal position for storage." b. "I will check the oxygen delivery equipment once every week." c. "I will restrict the length of the oxygen tubing to no longer than 3 feet." d. "I will make sure that electrical devices in the house are grounded."

"I will make sure that electrical devices in the house are grounded." Rationale: This response by the guardian indicates an understanding of the nurse's instructions. Due to the combustible nature of oxygen, all pieces of electrical equipment in the home should be grounded to decrease the risk of a fire caused by an electrical spark.

A nurse is caring for an adolescent client who is a practicing Jehovah's Witness and is scheduled for surgery for a ruptured appendix. The adolescent tells the nurse that based on their religious beliefs, they cannot receive a blood transfusion. Which of the following responses should the nurse make? a. "I will let the surgical team know your wishes." b. "Let's discuss the possible need for a transfusion with your parents." c. "You'll only receive blood during the procedure if you need it." d. "Why do members of your faith believe this?"

"Let's discuss the possible need for a transfusion with your parents." Rationale: The nurse should offer to involve the child's parents to understand the family's beliefs about blood transfusions.

A nurse is reinforcing teaching about glucose monitoring with the parent of a child who has type 1 diabetes mellitus. Which of the following instructions should the nurse include in the teaching? a. "Steady the finger against a hard surface while puncturing the skin." b. "Put your child's finger under warm, running water prior to collecting blood." c. "Obtain the blood sample from the center of your child's finger pad." d. "Press the platform of the lancet firmly against your child's finger."

"Put your child's finger under warm, running water prior to collecting blood." Rationale: The nurse should instruct the parent that placing the child's finger under warm, running water increases the blood flow to the finger, which will make it easier to obtain the sample.

A nurse is collecting data from a 12-month-old infant during a well-child visit. The nurse should identify which of the following findings as a deviation from expected growth and development? a. Negative Babinski reflex b. Birth weight doubled c. Unable to build a two-block tower d. Vocabulary of three words

Birth weight doubled Rationale: The nurse should identify this finding as a deviation from expected growth and development. The infant's birth weight should triple by 12 months of age. Therefore, the nurse should report this finding to the provider.

A nurse is assisting with the care of a child who has tonic-clonic seizures. Which of the following actions should the nurse take? a. Place a padded tongue blade at the bedside. b. Have a suction canister and tubing available in the room. c. Ensure the availability of soft extremity restraints. d. Keep the child's bed in the highest position.

Have a suction canister and tubing available in the room. Rationale: The nurse should have a suction canister and tubing available in the child's room to keep the child's airway patent during a seizure.

A nurse in a pediatric clinic is observing for an anaphylactic reaction after administering an IM antibiotic to a child 5 min ago. Which of the following manifestations should the nurse expect to observe first? a. Hives b. Angioedema c. Wheezing d. Hypotension

Hives Rationale: The nurse should observe for hives first because this is an early manifestation of an anaphylactic reaction.

A nurse is collecting data about a 4-year-old preschooler's gross motor skills. The nurse should expect the preschooler to be able to perform which of the following activities? a. Skipping on alternate feet b. Roller skating c. Hopping on one foot d. Jumping rope

Hopping on one foot Rationale: The nurse should expect to find that a 4-year-old preschooler is able to hop on one foot.

A nurse is monitoring a preschooler following an abdominal CT scan with contrast dye. The nurse should identify which of the following as an indication that the preschooler experienced an allergic reaction to the contrast dye? a. Urticaria b. Jaundice c. Petechiae d. Hematuria

Urticaria Rationale: The nurse should monitor the child for an allergic reaction to the contrast dye. Manifestations of the allergic reaction include urticaria, itching, flushing of the skin, and possible anaphylaxis.

A nurse in a pediatric clinic is collecting data from an infant who was recently exposed to pertussis. The nurse should recognize which of the following as a manifestation of pertussis? a. dry cough b. abdominal pain c. muscle stiffness d. swollen eyelids

dry cough Rationale: The nurse should identify that a dry cough is an early manifestation of pertussis.

A nurse is contributing to the plan of care for a school-age child who has acute poststreptococcal glomerulonephritis (APSGN) and is mildly hypertensive. Which of the following actions should the nurse include in the plan of care? a. Weigh the child every other day. b. Restrict the child's sodium intake. c. Monitor the child's blood pressure every 12 hr. d. Place the child on bed rest.

Restrict the child's sodium intake. Rationale: The nurse should limit the sodium intake for a child who has APSGN and is hypertensive or who has a decreased urine output to help prevent water retention and edema.

A nurse is reviewing the laboratory report of a school-age child who is receiving prednisone. Which of the following laboratory results should the nurse report to the provider? a. Potassium 4.2 mEq/L b. Fasting blood glucose 74 mg/dL c. WBC count 9,400/mm3 d. Sodium 150 mEq/L

Sodium 150 mEq/L Rationale: Hypernatremia is an adverse effect of prednisone. This level is above the expected reference range for a school-age child. Therefore, the nurse should report this value to the provider.

A nurse is reinforcing teaching with the parents of a 7-year-old female child about behavioral expectations. Which of the following behaviors should the nurse include in the teaching? a. Exhibits a decline in self-esteem b. Spends a lot of time by herself c. Selectively chooses a best friend d. Shows a competitive nature with others

Spends a lot of time by herself Rationale: Spending time alone is an expected characteristic of a 7-year-old female child. When they do spend time with others, children in this age group prefer to socialize with children of the same sex and age.

A nurse in a clinic is collecting data from an adolescent who has received all recommended immunizations through the age of 6 years. Which of the following immunizations should the nurse plan to administer? a. Haemophilus influenza type b (Hib) b. Rotavirus (RV) c. Polio (IPV) d. Tetanus, diphtheria toxoids, and acellular pertussis (Tdap)

Tetanus, diphtheria toxoids, and acellular pertussis (Tdap) Rationale: The Tdap vaccine is recommended between the ages of 11 and 12 years. Therefore, this adolescent should receive the Tdap vaccine now.

A nurse is reinforcing teaching with the family of a preschooler whose parent has a terminal diagnosis. Which of the following statements should the nurse include when discussing age-appropriate responses to death? a. "Your child will likely be curious about what happens to the body after death." b. "At this age, your child likely believes his thoughts can cause another person's death." c. "At this age, your child will understand that death is irreversible." d. "Your child will likely exhibit fear of the impending death with verbal uncooperativeness."

"At this age, your child likely believes his thoughts can cause another person's death." Rationale: The nurse should reinforce that, at this age, the preschooler might believe that his thoughts can cause another person's death, which can make him feel guilty or responsible for the death.

A nurse is reinforcing dietary teaching with the guardian of a school-age child who has celiac disease. Which of the following foods should the nurse recommend including in the child's diet? a. white rice b. whole wheat bread c. graham crackers d. french fries

white rice Rationale: The nurse should reinforce to the guardian that celiac disease is a genetic autoimmune disorder in which eating gluten, even in very small amounts, can damage the child's small intestine. Currently, the only treatment for the disease is a lifelong, strict adherence to a gluten-free diet. The nurse should stress the importance of avoiding foods containing wheat, rye, barley, and oats. The child should consume foods that are gluten-free, such as milk, cheese, rice, corn, eggs, potatoes, fruits, vegetables, fresh poultry, meats, fish, and dried beans.

A nurse is reinforcing discharge teaching with the parent of a school-age child who is being treated for nephrotic syndrome. The parent asks the nurse why it is necessary to check the child's urine for protein. Which of the following explanations should the nurse offer? a. "Protein in the urine indicates a need to begin dialysis." b. "Protein in the urine indicates your child's protein intake is adequate." c. "An increase in urine protein indicates your child has a secondary infection." d. "A decrease in urine protein indicates that treatment is effective."

"A decrease in urine protein indicates that treatment is effective." Rationale: The desired outcome of steroid therapy in the treatment of nephrotic syndrome is a reduction of proteinuria.

A nurse is reinforcing teaching with the parents of a toddler who has strabismus. Which of the following treatments should the nurse plan to include in the teaching? a. Laser surgery b. Artificial tears c. Eye patch d. Corrective biconcave lenses

Eye patch Rationale: Treatment of strabismus includes covering the strong eye to strengthen the muscles in the weak eye.

A nurse is assisting with the administration of a nasogastric enteral feeding for an infant. Which of the following actions should the nurse take? a. Auscultate over the infant's epigastric area to ensure proper tube placement. b. Place the infant in semi-Fowler's position for 1 hr after the feeding. c. Flush the tube with 30 mL of normal saline before the feeding. d. Warm the feeding in the microwave immediately prior to administration.

Place the infant in semi-Fowler's position for 1 hr after the feeding. Rationale: The nurse should elevate the head of the infant's bed by 30º to 45º for 30 min to 1 hr after the feeding.

A nurse is reinforcing teaching about home safety with the parent of a toddler. Which of the following parent statements indicates an understanding of the teaching? a. "I will place a screen in front of the fireplace." b. "I will keep my medication in my purse." c. "I will use a steam vaporizer when my child has a cold." d. "I will keep my hearing aid batteries in my bedside table."

"I will place a screen in front of the fireplace." Rationale: The nurse should instruct the parent to place a screen in front of a fireplace or other heating appliances to prevent burns.

A nurse is reinforcing teaching with an adolescent female client who has acne vulgaris and a new prescription for isotretinoin. Which of the following information should the nurse include? a."You should apply this medication to the affected skin twice daily." b. "You will need to have two negative pregnancy tests prior to starting this medication." c. "Your provider will prescribe a vitamin A supplement to take with each dose of this medication." d. "Your provider will monitor your kidney function while you are taking this medication."

"You will need to have two negative pregnancy tests prior to starting this medication." Rationale: The nurse should reinforce with the client that isotretinoin is teratogenic. Pregnancy must be ruled out prior to administration and before each subsequent refill. The client should use two effective forms of contraception while taking this medication.

A nurse in a community center is reinforcing teaching about poison control with a group of parents. A parent asks what to do if a child ingests a large quantity of acetaminophen. Identify the sequence of actions the nurse should recommend to the parent. (Move the steps into the box on the right, placing them in the order of performance. All steps must be used.) 1. Call a poison control center 2. Empty the child's mouth of remaining pills and reside 3. Identify the medication and dosage strength 4. Determine if the child is breathing

1st--Determine if the child is breathing 2nd--Empty the child's mouth of remaining pills and reside 3rd--Identify the medication and dosage strength 4th Call a poison control center Rationale: Determine if the child is breathing is the first step. The child's respiratory and cardiovascular status should be checked first to determine if CPR is necessary. Empty the child's mouth of remaining pills and residue is the second step. The child's mouth should be emptied of pills and residue to prevent additional exposure to the medication. Identify the medication and dosage strength is the third step. The parent should identify the medication and dosage strength by looking at the medication container. Call a poison control center is the fourth step. The parent should contact a poison control center for advice on the next course of action.

A nurse is caring for a school-age child who has been admitted to the facility in sickle cell crisis. The nurse is measuring the child's oral intake for the shift. The child consumed 4 oz of juice at breakfast. For lunch, the child consumed 6 oz of milk, 6 oz of gelatin, and drank 7 oz of water. What is the child's oral intake for this shift in milliliters? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

690mL

A nurse has just received change-of-shift report for four children in a pediatric unit. Which of the following children should the nurse collect data from first? a. A child who has a fever and nuchal rigidity b. A child who is 2 days postoperative following an appendectomy and reports incisional pain c. A child who experienced a seizure 1 hr ago and is resting d. A child who has a new diagnosis of diabetes mellitus and an HbA1c level of 7.5%

A child who has a fever and nuchal rigidity Rationale: A child who has a fever and nuchal rigidity is unstable. This finding indicates bacterial meningitis, which requires urgent data collection and intervention to reduce complications for the child and prevent further spread of the infection. Therefore, the nurse should collect data from this child first.

A nurse is assisting the provider with a developmental assessment of a toddler. Which of the following behaviors should the nurse recognize as an expected finding? a. Stands on one foot for several seconds b. Uses scissors to cut out shapes c. Prints letters with a pencil d. Walks backward with heel to toe

Stands on one foot for several seconds Rationale: Standing on one foot for several seconds is an expected behavior for a toddler.

A nurse is collecting data about the dietary habits of an adolescent female client. The nurse should identify that which of the following findings puts the client at risk for nutritional deficits? a. The client fasts twice a week to manage dietary intake. b. The client chooses to eat more vegetables than fruits. c. The client increases their dietary intake during track season. d. The client consumes approximately 2,000 calories a day.

The client fasts twice a week to manage dietary intake. Rationale: The nurse should identify that adolescents are often at risk for developing poor eating habits. Regular fasting puts this client at risk for nutritional deficits.