NCLEX Pediatrics

A school nurse is caring for a child who fell on the playground. Upon examination of the child, the nurse notes multiple bruises in various stages of healing. What is the nurse's initial intervention? 1. Ask the parents who hit the child on the back. 2. Notify the child's primary healthcare provider. 3. Contact the Department of Health and Human Services. 4. Document the findings and observe the child over the next week.

3. Contact the Department of Health and Human Services. (3. Correct: Unless there is a policy to direct otherwise, the nurse who suspects child abuse is obligated to report it to the Department of Health and Human Services (DHS). 1. Incorrect: This is confrontational and will warn the parents that you suspect abuse. This may lead to greater harm for the child. 2. Incorrect: Unless there is a policy to direct otherwise, the nurse who suspects child abuse is obligated to report it to the Department of Health and Human Services. DHS, rather than the primary healthcare provider can intervene to maintain the child's safety. 4. Incorrect: This is delaying care. If the child is being abused, not reporting it could lead to serious injury or even death.)

The parents of a toddler are worried about their child's poor meat intake resulting in a low iron level. What would be the best recommendation for the nurse to make? 1. Offer split pea soup once a week with a glass of milk. 2. Provide spinach twice a week. 3. Cook with an iron skillet. 4. Encourage fresh fruit intake.

3. Cook with an iron skillet. (3. Correct: Possibly one of the greatest cast iron skillet health benefits is that it adds iron to food. Many people suffer from iron deficiency and cooking with cast iron pans can help increase iron content by as much as 20 times. 1. Incorrect: The body may only absorb as little as 2 percent of the iron in legumes, such as lentils, black beans and split peas unless given with foods high in vitamin C. Milk will decrease absorption of iron. 2. Incorrect: Spinach is a source of non-heme iron, which is found in vegetable sources. Non-heme iron is not as bioavailable to the body as the heme iron found in animal products. Raw spinach contains an inhibitor called oxalic acid or oxalate. Oxalic acid naturally binds with minerals like calcium and iron, making them harder for the body to absorb. Cooking spinach can help unlock these iron absorption inhibitors and hence increase iron bioavailability. In other words, cooking spinach helps make iron more available to your body. However, once a week would not provide enough iron. 4. Incorrect: Fresh fruit increases fiber not iron. Fruit is high in vit C (Foods high in vitamin C include citrus fruits, dark green leafy vegetables, bell peppers, melons and strawberries). Good food sources of beta-carotene and vitamin A include carrots, sweet potatoes, spinach, kale, squash, red peppers, cantaloupe, apricots, oranges and peaches.)

What information should be included in the health promotion plan for parents regarding the promotion of adequate bowel elimination in their toddler? Select all that apply 1. Include adequate fiber in the diet through whole grains and fruits. 2. Increase intake of water daily. 3. Provide toileting opportunities that are free from distractions. 4. Encourage the toddler to go to the bathroom at least three times daily. 5. Take away attention from the toddler unable to potty.

1. Include adequate fiber in the diet through whole grains and fruits. 2. Increase intake of water daily. 3. Provide toileting opportunities that are free from distractions. (1., 2. & 3. Correct: Fiber is important for achieving adequate bowel elimination. Fruits and whole grains may help. Water intake is important, coupled with adequate fiber. Distractions at toileting times may result in poor elimination results. 4. Incorrect: The toddler should be taken to the bathroom after meals and at bedtime to encourage adequate elimination. Routine is very important. Peristalsis increases after meals. 5. Incorrect. Embarrassment or punitive measures will not yield positive results. Rather, the toddler should be praised for using the potty.)

What developmental milestone does the nurse expect to see in an 18 month old toddler? Select all that apply 1. Says and shakes head "no". 2. Points to one body part. 3. Drinks from a cup. 4. Points to show someone what they want. 5. Kicks a ball. 6. Walks up and down stairs holding on.

1. Says and shakes head "no". 2. Points to one body part. 3. Drinks from a cup. 4. Points to show someone what they want. (1., 2., 3., & 4. Correct: By the age of 18 months, the nurse would expect the baby to say and shake the head "no", point to a body part, drink from a cup, and point to what they want. 5. Incorrect: The nurse should expect to see the baby watch the path of something as it falls. It is a little to early to expect the 18 month old to do this. 6. Incorrect: The 2 year old can accomplish walking up and down stairs while holding on. The 18 month old is not physically ready to do this.)

The parents of a 4 year old child have recently had a new baby and the parents report that the 4 year old had been dry all night for 8 months and is now wetting the bed again. What should the nurse assess first? 1. Urinalysis 2. Normal urination habits. 3. Adjustment to the new baby. 4. Fluid intake after 6 pm.

1. Urinalysis (1. Correct: Always assess the physiologic problem first to rule out a urinary tract infection (UTI). Once a physiologic cause is removed as the cause other assessment should be performed. If a UTI is present, treatment should start immediately. 2. Incorrect: Assessing the normal urination habits is not first. Assessing the urinalysis is priority. 3. Incorrect: Regression is the likely cause but the physiologic problems should be assessed first. 4. Incorrect: The child's fluid intake may be too high after 6 pm, but ruling out a urinary tract infection is the first assessment and requires immediate treatment if there is an infection.)

The nurse is working on a health promotion plan for a young family whose child has severe allergies and asthma symptoms. Which interventions would be important to include in the health promotion plan? Select all that apply 1. Wash stuffed animals/toys frequently in hot water. 2. Make sure that bathrooms and high humidity areas are properly vented. 3. Limit carpet in the bedrooms. 4. Use humidifiers regularly. 5. Vacuum floors and upholstered furniture regularly.

1. Wash stuffed animals/toys frequently in hot water. 2. Make sure that bathrooms and high humidity areas are properly vented. 3. Limit carpet in the bedrooms. 5. Vacuum floors and upholstered furniture regularly. (1., 2., 3. & 5. Correct: The frequent washing in hot water removes dust mites. Adequate venting lessens the likelihood of fungal/mold spores. Carpet harbors dust and other allergens. The floors and upholstered furniture may harbor dust, pollen from clothing, and other irritants. 4. Incorrect: Humid air may contribute to mold or fungal spores in the house. Less humidity is appropriate.)

What developmental milestone does the nurse expect to see in a 4 year old child? Select all that apply 1. Can say first and last name. 2. Draws a person with 2 to 4 body parts. 3. Copies a triangle. 4. Can tell what is real and what is make believe. 5. Sings a song from memory. 6. Talks about likes and interests.

1. Can say first and last name. 2. Draws a person with 2 to 4 body parts. 5. Sings a song from memory. 6. Talks about likes and interests. (1., 2., 5., & 6. Correct: By the age of 4 years, the nurse would expect the child to know both their first and last name, be able to draw a person with 2-4 body parts, sing a song from memory such as the "Itsy Bitsy Spider" or the "Wheels on the Bus", and talk about what they like and are interested in. 3. Incorrect: When checking the developmental milestones of a 5 year old, the nurse should expect to see the child to be able to copy a triangle. 4. Incorrect: The 5 year old can distinguish between reality and make believe. The 4 year old often cannot tell the difference.)

At a well-baby check, the parents of a 14 month old report how the child is doing and then excitedly share that they have purchased and are moving into a "fixer-up" home that was built in the mid-1960s. Based on the parent's report, what would be the priority concern for the nurse to address with the parents? 1. Fall risk due to increased mobility 2. Increased anxiety due to change in the environment 3. Speech consisting of only 4 words 4. Potential for lead poisoning

4. Potential for lead poisoning (4. Correct: Since the home that they are moving into was built before 1978, there is a high likelihood that it has lead-based paint. One of the most common causes of lead poisoning is lead from paint, including dust that is contaminated with lead. Lead-based paint that is peeling, chipping, cracking, or damaged is a hazard that requires immediate attention. Young children, such as this 14 month old, are at high risk for lead poisoning as they may chew on painted surfaces or may come in contact with painted surfaces that often have areas of wear-and-tear such as window sills, door frames, railings, etc. In addition, remodeling or renovating activities as well as scraping old paint can create toxic lead dust. The reason that this is the priority concern is that even low levels of lead in the blood in children could result in learning and behavior problems, delayed growth, anemia, hearing problems, hyperactivity, and lower IQ. In more severe cases, lead ingestion can cause seizures, coma, and possibly death. 1. Incorrect: Yes, 14 month old children are likely to experience some tumbles and bumps. This is normal for this age child as depth perception and coordination are not fully developed and they are learning the skills of increased mobility. However, these are not generally of great concern under normal circumstances and certainly do not take priority over the concern for lead poisoning. 2. Incorrect: Toddlers tend to do better with routines that are predictable. Changes in the routine can cause the toddler to become anxious. Moving to a new home would be very disruptive to this 14 month old's routine. This anxiety could be manifested by increased clinginess, regression, decreased appetite, and other unusual behaviors such as increased aggressive behaviors, shyness, and anxious habits (twirling hair, clinging to and rubbing favorite blanket, etc.). Even though these behaviors may be concerning and would need to be addressed, they would not be a priority over the effects that lead poisoning could cause. 3. Incorrect: The speech of the 14 month old is still early in the developmental process and can vary from child to child. A 14 month old's vocabulary normally consists of about three to five words. So, this 14 month old with a vocabulary of 4 words is not abnormal and would not be of concern to the nurse.)

Which room assignment would be most therapeutic for the nurse to make for a client with bipolar disorder in manic phase who is hyperactive and has difficulty sleeping? 1. A private bedroom. 2. A semi private room with a roommate who has a similar problem. 3. Either a private or a semi private room. 4. Direct admission to the seclusion room until his activity level becomes more subdued.

1. A private bedroom. (1. Correct: A private room will help to decrease stimulation. The client with bipolar disorder needs a calm environment especially when in the manic phase. Avoid excessive stimulation. 2. Incorrect: Don't put two manics together. This room assignment will not help to decrease stimulation which is what the manic client needs. 3. Incorrect: They need a private room. The client with psychosis maybe suspicious and have delusion or hallucinations. 4. Incorrect: There's no need for this right now. The client is hyperactive and has difficulty sleeping. A seclusion room is needed for severe agitation and acute aggression.)

The nurse is reviewing the immunization record of a 3 month old. Which immunization does the nurse expect the child to have received by this age? 1. First Hepatitis B vaccination. 2. Second diphtheria vaccination. 3. Third Hib vaccination. 4. Influenza vaccination.

1. First Hepatitis B vaccination. (1. Correct: In the US the first dose is recommended at birth. In Canada, the first dose is recommended between birth and two months. 2. Incorrect: In both the US and Canada, the first diphtheria vaccination is recommended at 2 months, and the second at 4 months. 3. Incorrect: In both the US and Canada, the first Hib vaccination is recommended at 2 months, the second at 4 months, and the third at 6 months. 4. Incorrect: In both the US and Canada, all healthy children ages 6 months and older should receive a yearly influenza vaccination.)

A new mother asks the clinic nurse why her baby should receive recommended vaccinations. What is the best response by the nurse concerning vaccinations? 1. "Vaccinations give antibodies to your baby to protect them from disease." 2. "Vaccinations will help your baby produce antibodies against disease causing organisms." 3. "Federal law requires that your baby receive recommended vaccinations." 4. "There is no reason not to vaccinate your baby since only mild, uncomfortable reactions can occur."

2. "Vaccinations will help your baby produce antibodies against disease causing organisms." (2. Correct: Vaccines are suspensions of antigen preparations intended to produce a human immune response to protect the person from future encounters with the organism. 1. Incorrect: Vaccines will cause the body to produce antibodies. Vaccines give possible immunity to the baby. 3. Incorrect: Vaccines are required for admittance into public school. If a child is homeschooled, the parent may not have the child vaccinated. 4. Incorrect: It is true that the vaccination may cause a mild reaction, but this is not the best response. This answer does not address the mother's question.)

The nurse should assess for what signs of toxicity in a child who is admitted with salicylate overdose? Select all that apply 1. Hypoventilation 2. Vomiting 3. Tinnitus 4. Diaphoresis 5. Dehydration 6. Hypothermia

2. Vomiting 3. Tinnitus 4. Diaphoresis 5. Dehydration (2., 3., 4., & 5. Correct: Nausea and vomiting are the most common toxic effects. This can be caused by CNS toxicity or by direct damage to the gastric mucosa. Salicylates can be neurotoxic, and this is manifested by ringing in the ears. Ototoxicity can also lead to hearing loss. Diaphoresis results in the early phase of toxicity. Serious dehydration can result from insensible losses due to hyperventilation and fever, as well as active losses due to vomiting. 1. Incorrect: The first phase of salicylate toxicity is characterized by hyperventilation due to stimulation of the respiratory center in the brain. This is a key feature of salicylate toxicity. 6. Incorrect: Hyperpyrexia is an indication of severe toxicity, especially in younger children.)

Which assignment by the charge nurse would be most appropriate for a general pediatric nurse being reassigned to the hematology/oncology pediatric unit? Select all that apply 1. Child dying with leukemia who has been on the hematology/oncology unit for two weeks. 2. Teenager with sickle cell disease in for pain management. 3. Child admitted following a bicycle accident that has idiopathic thrombocytopenic purpura (ITP). 4. New admit scheduled for bone marrow transplant. 5. Child diagnosed with leukemia admitted for stomatitis.

2. Teenager with sickle cell disease in for pain management. 3. Child admitted following a bicycle accident that has idiopathic thrombocytopenic purpura (ITP). 5. Child diagnosed with leukemia admitted for stomatitis. (2., 3., & 5. Correct: The nurse should be given an assignment similar to the type of clients and skill level the nurse is accustomed to on the general pediatric unit. Therefore, the choices should be these three clients. Even though one of the clients has leukemia, the child is being treated for stomatitis, not the leukemia. Sickle cell clients are frequently cared for on general pediatric units. The reassigned nurse has the knowledge and skills needed to meet the clients needs for pain management and treatment for the sickle cell disease. The general pediatric nurse should be competent in caring for children with low platelet counts, so the child with ITP could be assigned to this nurse. The nurse would be familiar with bleeding precautions, monitoring for bleeding, and associated care. 1. Incorrect: This client is dying with leukemia and needs consistency in the staff assigned to care for them. Although the general pediatric nurse could competently care for a dying child, the focus should be on the client. This child needs and deserves consistent care and care by those that are familiar to this child. 4. Incorrect: A child who is to receive a bone marrow transplant would not be the best assignment, since the nurse must have special preparation and an understanding of the protocol with a bone marrow transplant client. This is not something that a general pediatric nurse would typically do. Therefore, this client would need to be cared for by the nurses on the hematology/oncology unit who has this special training and/or knowledge.)

The nurse is talking to the parents of a 4 year old who is suspected to have iron deficiency anemia. What statement by the parents would suggest the cause of this anemia to the nurse? 1. "Breakfast consists of iron fortified cereal most days." 2. "A typical lunch would be a chicken sandwich with orange slices." 3. "Our child drinks 30 ounces (887 mL) of milk a day." 4. "It is difficult to get our child to eat broccoli."

3. "Our child drinks 30 ounces (887 mL) of milk a day." (3. Correct: Drinking excess amounts of milk may lead to iron deficiency because the calcium in milk blocks iron absorption. 1. Incorrect: ¾ cup of 100% iron fortified prepared cereal provides 18 mg of iron. 2. Incorrect: The body's absorption of iron increases when drinking citrus juice or eating other foods rich in vitamin C (oranges) while high-iron foods (chicken) are eaten. 4. Incorrect: Broccoli is rich in calcium, not iron.)

A concerned mother is asking the nurse about activities that would be best for her child who has been diagnosed with asthma. In order to minimize the risk of exercise induced asthma, which activity would be best for the nurse to suggest? 1. Track 2. Basketball 3. Baseball 4. Soccer

3. Baseball (3. Correct: Baseball is an activity that is considered "asthma friendly". It requires short, intermittent periods of exertion and is therefore tolerated better by children with asthma. 1. Incorrect: This activity requires extended periods of exertion and is not considered "asthma friendly" and often not tolerated by clients with asthma. 2. Incorrect: This activity requires extended periods of exertion and is not considered "asthma friendly" and often not tolerated by clients with asthma. 4. Incorrect: This activity requires extended periods of exertion and is not considered "asthma friendly" and often not tolerated by clients with asthma.)

At what age does the nurse expect to see a child build a tower of 9 blocks? 1. One 2. Two 3. Three 4. Four

3. Three (3. Correct: By the age of 3 years, the nurse would expect the child to build a tower of 9-10 blocks. 1. Incorrect: At one the child is working on gross motor skills rather than dexterity skills. 2. Incorrect: By age 2 the child can build a tower of at least 4 blocks. 4. Incorrect: The four year old can build high towers of more than 10 blocks.)

A pediatric nurse is teaching a group of new parents about what to expect regarding their infants eyes and vision. What points should the nurse include? Select all that apply 1. At 4 weeks of age, the infant should be able to gaze at objects. 2. Infants should have tears by the age of 1 month. 3. Visual acuity is about 20/300 at 4 months of age. 4. During the first 2 months of life, infant's eyes may appear to be crossed. 5. Depth perception begins around the 5th month of age.

1. At 4 weeks of age, the infant should be able to gaze at objects. 3. Visual acuity is about 20/300 at 4 months of age. 4. During the first 2 months of life, infant's eyes may appear to be crossed. 5. Depth perception begins around the 5th month of age. (1., 3, 4, & 5. Correct: At birth, babies have not yet developed the ability to easily tell the difference between two targets or move their eyes between the two images. Their primary focus is on objects 8 to 10 inches from their face or the distance to parent's face. Babies should begin to follow moving objects with their eyes and reach for things at around three months of age. When taking photos, the parent will begin to notice the baby blinking at the flash. Visual acuity is still in the 20/200 to 20/400 range. Infants are beginning to recognize familiar people, and by 3 months they should be reaching for things. For the first two months of life, an infant's eyes are not well coordinated and may appear to wander or to be crossed. This is usually normal. However, if an eye appears to turn in or out constantly, an evaluation is warranted. By 4 months the child's eyes should be working together. He or she should begin to follow objects and people, recognize familiar objects, as well as watch parents' faces when being talked to. 2. Incorrect: Infants do not have tears until about 3 months of age.)

The nurse is conducting a developmental screening by first gathering history information from the parent of a toddler. What information obtained by the parent would the nurse consider a risk factor for developmental problems? Select all that apply 1. Birthweight less than 3 pounds, 4 ounces (1.5 kg). 2. Gestational age less than 36 weeks. 3. Chronic otitis media with effusion for more than 3 months. 4. Lead level of 5.5 mg/dL 2 months ago. 5. Parents with 8th grade education.

1. Birthweight less than 3 pounds, 4 ounces (1.5 kg). 3. Chronic otitis media with effusion for more than 3 months. 4. Lead level of 5.5 mg/dL 2 months ago. 5. Parents with 8th grade education. (1., 3., 4., & 5. Correct: Factors placing the infant or toddler at risk for developmental problems include birthweight less than 3 pounds, 4 ounces (1.5 kg), chronic otitis media with effusion for more than 3 months, lead levels above 5.0 mg/dL, and parents with less than a high school education. The months a baby spends in the uterus, along with the first 12 months after birth, are the most important time of brain development. During this period neurons are forming connections with each other, creating the networks that underlie thinking, learning, and feeling. In the last weeks of pregnancy, as many as 40,000 new synapses are being formed every second. Preterm birth (less than 37 weeks gestational age) and low birth weight (less than 2.5 kg) are well-documented risk factors. In addition to threatening healthy overall growth and maturation, premature infants and low birth weight term infants may experience a disruption of important processes involved in early brain development. As a result, preterm and low birth weight children, are at increased risk for a variety of developmental problems related to health, psychological adjustment, and intellectual functioning. There is evidence that sensorineural hearing loss may result from chronic otitis. There is also evidence that the auditory deprivation associated with childhood otitis media may lead to language and speech delays. Lead is a neurotoxic substance that has been shown in numerous research studies to affect brain function and development. Children who have been exposed to elevated levels of lead are at increased risk for cognitive and behavioral problems during development. Studies show that low socioeconomic status, as measured by low income, wealth, or parental education, is associated with poor child development outcomes. 2. Incorrect: Gestational age less than 37 weeks places the infant or toddler at risk for developmental problems.)

A nurse is planning an educational session on safety for parents of young children. What safety points should the nurse include? Select all that apply 1. Teach children the basics of swimming. 2. Plan an escape route in the event of fire. 3. Make sure that sand surrounds the playground equipment. 4. Gates should be placed at the top and bottom of stairs when toddlers are present. 5. Vitamins should be referred to as candy so that children will take them. 6. A child at age 7 may sit in the front seat of a car.

1. Teach children the basics of swimming. 2. Plan an escape route in the event of fire. 3. Make sure that sand surrounds the playground equipment. 4. Gates should be placed at the top and bottom of stairs when toddlers are present. (1., 2., 3., & 4. Correct: Everyone should know the basics of swimming (floating, moving through the water) and cardiopulmonary resuscitation (CPR). Create and practice a family fire escape plan and involve kids in the planning. Make sure everyone knows at least two ways out of every room and identify a central meeting place outside. Falls on playgrounds are common and can cause serious injury. Wood chips or sand, not dirt or grass should be under playground equipment. Having a gate at the top and bottom of stairs can prevent falls. 5. Incorrect: Do not tell children that medication, even vitamins, is candy. Children may take medicine because they think it really is candy when they see medication not intended for them. 6. Incorrect: Children should not sit in the front seat of a car until 8-12 years of age or they are 4ft. 9in. (145 cm) in height.)

The nurse working on a pediatric unit is reviewing morning laboratory results. What client's lab result should be immediately reported to the primary healthcare provider? Client one: Fasting Glucose 140 mg/dL, Creat./BUN 0.6/23 mg/dL, USG 1.020 Client two: Fasting Glucose 99 mg/dL, Creat./BUN 1.8/35 mg/dL, USG 1.026 Client three: Fasting Glucose 80 mg/dL, Creat./BUN 1.4/26 mg/dL, USG 1.035 Client four: Fasting Glucose 75 mg/dL, Creat./BUN 0.6/20 mg/dL, USG 1.012 1. Client one - newly diagnosed with type I diabetes. 2. Client two - admitted with acute glomerulonephritis. 3. Client three- treated with IV fluids for sickle cell crisis. 4. Client four - transferred in with pneumococcal pneumonia.

3. Client three- treated with IV fluids for sickle cell crisis. (3. Correct: Though many of the laboratory results are abnormal, the most concerning is the urine specific gravity in Client three, treated for sickle cell crisis. This result indicates the client is extremely dehydrated, which could lead to more complications, further exacerbating the crisis. 1. Incorrect: A child newly diagnosed with type I diabetes requires some time for the body to respond to treatment and insulin injections. Even though hospitalized, the child may periodically have elevated blood glucose readings during this adjustment period. The slightly elevated specific gravity is to be expected since hyperglycemia causes dehydration in the body. 2. Incorrect: Glomerulonephritis is an inflammatory process within the glomeruli of the kidneys, caused by a type of beta-hemolytic streptococcal infection. The elevated renal labs are to be expected with this illness, and are not abnormal enough to cause undue concern. 4. Incorrect: The client has been transferred to this unit with a diagnosis of pneumococcal pneumonia, which is very serious in children. Because of this illness, an elevated white blood count is expected. The remaining labs are within normal limits. No need to report any values here.)

A 12 year old female, with a history of juvenile rheumatoid arthritis, is being admitted for re-evaluation. The child reported these symptoms for the last week: temperature of 102.9ºF/39.4ºC at 4:00 pm every day, increased pain in joints, loss of appetite, and fatigue. What would be an appropriate room assignment by the charge nurse? 1. Private room only. 2. Rooming with a 12 year old male in skeletal traction due to a fractured femur. 3. Rooming with a 10 year old female that has been admitted for sickle cell disease. 4. Rooming with a 14 month old female that has been admitted for orthopedic surgery.

3. Rooming with a 10 year old female that has been admitted for sickle cell disease. (3. Correct: The appropriate answer is to room her with the 10 year old being worked up for sickle cell disease. This is an acceptable age/sex to pair as roommates. Each has a chronic illness and this allows them to see how another person with limitations adjusts. 1. Incorrect: It is not necessary for this child to be in a private room. The fever at a particular time of the day is a symptom of juvenile rheumatoid arthritis and does not mean an infection. 2. Incorrect: It would be inappropriate to room her with a 12 year old male due to opposite sex and age. 4. Incorrect: The 12 year old who is in pain, feverish, and fatigued would be unable to rest as needed in a room with a 14 month old who is postoperative.)

A child receiving chemotherapy via a Port-a-cath needs blood cultures collected. In what order should the nurse complete this procedure? Access port with Huber needle. Flush port with heparin solution. Clean diaphragm with alcohol. Withdraw 10 mL blood into vial. Flush port with normal saline. Wash hands and don gloves.

Wash hands and don gloves. Clean diaphragm with alcohol. Access port with Huber needle. Withdraw 10 mL blood into vial. Flush port with normal saline. Flush port with heparin solution. (Obtaining blood from a Port-a-cath decreases other needle sticks to an immunocompromised client. Drawing blood cultures is a slightly different process than obtaining blood for other lab work. First: Wash hands and don non-sterile gloves. As a nurse, you know that any procedure begins with hand washing! Since there is no option for sterile gloves, this option must be the first step. Second: If the nurse has donned gloves, prepping the client would be the next logical step. Cleaning the port, in this case with an alcohol wipe, is all that is necessary. However, if port access is completed as a sterile technique, you may observe a nurse cleaning the diaphragm with chlorhexidine. Again, this question does not provide you that choice. Third: Now that the diaphragm is clean, it is accessed with the Huber needle. The needle would already be primed and connected to the adapter (small tubing with a vacutainer) into which the blood vial is inserted to withdraw the sample. Fourth: The nurse will withdraw 10 mL of blood into the appropriate blood vial or tube for the blood cultures. For blood cultures, the first vial of blood is not discarded, as with other types of laboratory tests. Fifth: The port is flushed with normal saline to rinse the inner catheter and clear any remaining blood out of the diaphragm. In some situations, the process may end with the saline flush. But not in this example. Sixth: The final step is to flush the port and inner tubing with heparin to prevent blood clots or occlusion from occurring inside the port itself. Again, this step is dependent upon the type of port and the sample needed.)

The nurse is talking with parents of school-aged children about promoting healthy eating in their children. What information should the nurse provide? Select all that apply 1. Skipping breakfast will decrease energy level and could lower school grades. 2. Freeze fruit before placing in lunch box to keep it tasting fresh. 3. Limit snacks to when the child is hungry, rather than bored. 4. Enforce rule that child must eat food even if they do not like it. 5. The parent should eat a variety of foods as an example to children. 6. Prepare homemade healthy version of favorite take out meals.

1. Skipping breakfast will decrease energy level and could lower school grades. 2. Freeze fruit before placing in lunch box to keep it tasting fresh. 3. Limit snacks to when the child is hungry, rather than bored. 5. The parent should eat a variety of foods as an example to children. 6. Prepare homemade healthy version of favorite take out meals. (1., 2., 3., 5., & 6. Correct: Don't let the child skip breakfast. The child will have less energy to play well later in the day. Skipping breakfast can also lower grades in school as concentration decreases. Freeze fruits before putting them in the lunch box. This will keep the lunch items cool and the fruit fresh tasty. Canned pineapple, bananas, and grapes freeze well. Children need to learn to eat only when they are hungry. Children often eat out of boredom. Discourage nonstop grazing by planning activities to occupy the child. Lead by example. Children eventually adopt the eating patterns of their parents. If they see the parents eat vegetables, they will eventually try them. Prepare homemade healthy versions of take out favorites. 4. Incorrect: Forcing children to eat foods they do not like will only deepen their dislike for them. Give them the healthy foods they do enjoy and eventually they will explore more options.)

A clinic nurse completed teaching the parents of a 9 month old baby how to prevent otitis media infections in their baby. Which statement by the parents indicates to the nurse that further teaching is necessary? 1. "Our baby should sit up for feedings." 2. "It is fine to prop up a juice bottle for our baby to drink at night." 3. "Since our baby has ear tubes, ear plugs should be worn when swimming." 4. "We need to keep our baby away from people who are smoking."

2. "It is fine to prop up a juice bottle for our baby to drink at night." (2. Correct: Propping up a bottle can contribute to otitis media and dental caries with a propped bottle, the liquid pools in the back of the mouth and can back up through the eustachian tube. Bacteria may then enter through the tube and cause an ear infection. 1. Incorrect: This is a correct response. Reflux of milk up the eustachian tubes is less likely in the vertical or semi-vertical position during feedings. 3. Incorrect: This is a correct statement. Parents should keep bath water and shampoo water out of the ear, if possible. Swimming without earplugs poses a slightly increased risk of infection. 4. Incorrect: This is a correct statement. Second hand smoking increases the risk of persistent middle ear effusion by enhancing attachment of the pathogens that cause otitis to the middle ear space, prolonging the inflammatory response and impeding drainage through the eustachian tube.)

A child diagnosed with gastroenteritis is being given fluids in the emergency room for severe dehydration. Prior to discharge, the nurse instructs the mother how to prepare a BRATT diet. The nurse knows the teaching was successful when the mother selects what foods for the child? Select all that apply 1. Raisins 2. Bananas 3. Apples 4. Toast 5. Rice 6. Tea

2. Bananas 4. Toast 5. Rice 6. Tea (2, 4, 5 and 6. Correct: The Bratt diet is useful for children following any type of gastroenteritis which included nausea, diarrhea or severe vomiting. This bland diet is used in the first 24 hours to allow the gut to rest and readjust slowly to foods that are low protein, low fat and low fiber. The BRATT diet is for short term use only and consists of bananas, rice, apple sauce, toast and tea. 1. Incorrect: Although raisins are normally a natural source of healthy fruit, they have too much fiber for an irritated gastric tract. They are not part of the BRAT diet. 3. Incorrect: Apples are high in fiber and natural sucrose, which is not appropriate for a child with severe gastroenteritis. However, apple sauce is part of the BRAT diet and is an excellent source of nutrition without stressing a weakened gastrointestinal system.)

What would be most important for the nurse to teach parents in order to promote sleep and rest in the preschool child? 1. Allow the child to choose own bedtime based on degree of fatigue. 2. Develop a consistent routine before going to bed. 3. Assess how much sleep the child requires. 4. Set a consistent wake-up schedule.

2. Develop a consistent routine before going to bed. (2. Correct: A consistent routine helps to prepare the child for sleep. Reading or telling stories before bedtime may help the child to relax and fall asleep more easily. Routines are very important for this age group. Doing specific things before bedtime can signal to the child that it is time to get ready for bed and to go to sleep. 1. Incorrect: Although important, this is not the priority. Establishing a routine is most important. A cool environment will promote rest. A child's sleep cycle is sensitive to light and temperature. Melatonin levels help to regulate the drop in internal temperature needed to sleep. 3. Incorrect: Assessing the amount of sleep needed can help with promoting sleep and rest but routine is priority in the preschool age group. 4. Incorrect: Setting a wake-up time prevents a child from over sleeping on weekends and holidays. Those extra hours can disturb the sleep cycle. For a preschooler routine is the priority answer to promote sleep and rest at night.)

The parents of a toddler ask the nurse how to stop their child's temper tantrums when they occur. What is the best advice the nurse should provide? 1. Spank the child gently when the tantrum occurs. 2. Promise the child a new toy if the child stops the tantrum. 3. Ignore the tantrum if the child is safe. 4. Restrain the child during a tantrum.

3. Ignore the tantrum if the child is safe. (3. Correct: When a tantrum occurs, the best course of action is to ignore the behavior and ensure that the child is safe during the tantrum. 1. Incorrect: Physical punishment will probably just prolong the tantrum and in fact produce more intense negative behavior. 2. Incorrect: Providing a reward to stop an inappropriate behavior will reinforce that behavior. Throw a temper tantrum, get a reward. 4. Incorrect: Restraining a child may prolong the temper tantrum and produce a more intense negative behavior. If the tantrum occurs in public, it may be necessary to immobilize the child with a big bear hug and use a calm voice to soothe the child.)

The nurse working in a pediatrician's office is teaching a couple with small children about proper medication administration for children. What statement by the couple would indicate that further teaching is needed? 1. We should carefully measure elixir medication with the provided dropper. 2. Our children should not watch us take medicine. 3. We tell our children the medicine is candy so they will take it without a fuss. 4. Even though medicine comes in a childproof container, we will put medication out of reach.

3. We tell our children the medicine is candy so they will take it without a fuss. (3. Correct: Calling medication "candy" is inappropriate and misleading to the child. Children may take medication to eat as candy if they have access to it. 1. Incorrect: This is a correct statement by the parents. Medication should be measured closely because too much or too little might cause harm to the child. 2. Incorrect: Taking medicine in front of children is not recommended, as children often try to imitate adult behavior. 4. Incorrect: All medication should be placed out of the reach of children.)

A preschool child has been rushed to the emergency room after ingesting an undetermined amount of chewable baby aspirin. What action should the nurse take immediately? 1. Inject subcutaneous dose of vitamin K. 2. Induce vomiting with ipecac. 3. Initiate large bore IV line. 4. Insert a nasogastric tube.

4. Insert a nasogastric tube. (4. Correct: The most urgent need in an overdose situation is to neutralize or inactivate the drug and/or poison. Activated charcoal is the treatment of choice for aspirin. In a child this young, the only way to instill the charcoal is via NG tube, which will also decrease the chance of aspiration. 1. Incorrect: Vitamin K is used as an antidote to reverse the effects of excessive warfarin. Although Vitamin K is used to decrease bleeding, it is not an appropriate or effective intervention for baby aspirin. 2. Incorrect: Inducing vomiting with syrup of ipecac is no longer considered an acceptable intervention for poisoning. Inducing vomiting increases the chance for aspiration and electrolyte imbalances. 3. Incorrect: Although an IV site will be important for fluid resuscitation, initiating an intravenous line is not the nurse's first priority.)

A school-aged child is being admitted for probable viral meningitis. What arrangement does the nurse need to make in order to prepare for this client? 1. Private room. 2. Negative air-flow room. 3. Droplet precautions including mask. 4. Needs standard precautions only.

4. Needs standard precautions only. (4. Correct: Viral meningitis is caused by a group of enteroviruses, such as those that also cause mumps or measles. School-aged clients generally fare better than very young children or infants. The Center for Disease (CDC) has determined that standard precautions are adequate for older children and adults. 1. Incorrect: A private room would be appropriate for bacterial meningitis and other highly contagious illnesses. This is not needed in the case of viral meningitis. 2. Incorrect: Negative air-flow is needed for serious illnesses such as active tuberculosis, SARS, Ebola or even certain types of chickenpox. Such a room would not be necessary for viral meningitis. 3. Incorrect: If there is close contact with a person who has viral meningitis, you may become infected with the virus that made that person sick. However, you are not likely to develop meningitis. That's because only a small number of people who get infected with the viruses that cause meningitis will actually develop viral meningitis. Standard precautions is the best way to prevent this virus.)

A nine year old child with attention deficit hyperactivity disorder (ADHD) is being admitted to the pediatric unit. Who should the charge nurse assign this client to room with? 1. Ten year old with Crohn's disease. 2. Eight year old with a history of seizures. 3. Six year old admitted with asthma. 4. Seven year old with a urinary tract infection.

4. Seven year old with a urinary tract infection. (4. Correct: It would be best to pair this child with the child with a urinary tract infection. They are close to the same age and this child's condition does not require a quiet environment that could be interrupted by a hyperactive child. 1. Incorrect: The ADHD clients behavior could be detrimental to the client's Crohn's disease. Crohn's disease is not caused by stress but it can make signs and symptoms worse and may trigger flare-ups. 2. Incorrect: You want to decrease stimulation when you have a client with seizures not increase it. Seizures can be precipitated by sensory stimuli. 3. Incorrect: Again, the client with asthma does not need any stimuli that could cause agitation and stress. Stress can trigger the release of chemicals like histamine and leukotriences which can trigger narrowing of the airways.)

The parents of a 1 month old report that their baby wakes up startled and stretches out the arms throughout the night. What suggestion should the nurse provide to the parents to decrease this reflex? 1. Rock to sleep. 2. Place in a baby swing. 3. Provide a pacifier. 4. Swaddle the baby.

4. Swaddle the baby. (4. Correct: Swaddling makes the baby feel more secure and decreases the baby's sense of falling. 1. Incorrect: The nurse wants to suggest something that will decrease the baby's sensation of falling. Rocking the baby will not accomplish this. 2. Incorrect: This startling occurs when the baby has a sense of falling. Placing in a baby swing will not decrease this response. 3. Incorrect: The nurse wants to suggest something that will decrease the baby's sensation of falling. A pacifier will not accomplish this.)

A nurse is working in a walk-in clinic where a mother brings in her 6 year old child stating, "My child is just not right." The nurse notes an unusual odor to the child's breath, new onset of bed-wetting, and lethargy. What prescription by the primary healthcare provider should be performed first? 1. Blood glucose 2. Urinalysis for white blood cells (WBC) 3. Oxygen saturation 4. Toxicology screen

1. Blood glucose (1. Correct: Type I diabetes usually has a sudden onset and many times diabetic ketoacidosis (DKA) is the first encounter. The symptoms in the stem: unusual odor to the breath, bed wetting, and lethargy are symptoms of DKA. The blood glucose is one of the most important tests for the diagnosis of DKA. 2. Incorrect: A urinalysis to assess WBC will not support the diagnosis of DKA. 3. Incorrect: In this case, oxygen saturation is not the priority. This child is not in respiratory distress. 4. Incorrect: A toxicology screen will not support a diagnosis of DKA; however, if the blood glucose was not elevated, it could provide further assessment data.)

What signs and symptoms will the nurse look for when caring for an infant with severe dehydration? Select all that apply 1. Dark, yellow urine 2. Lethargic 3. Bulging fontanels 4. Tachypnea 5. Decreased urine output

1. Dark, yellow urine 2. Lethargic 4. Tachypnea 5. Decreased urine output (1., 2., 4., & 5. Correct: These would be signs and symptoms of dehydration in an infant. Amber or dark urine is an indication of dehydration. Urine should be a clear, pale yellow. Fussiness and irritability are seen in infants when they do not feel well. As dehydration worsens, lethargy and unresponsiveness can develop. Tachypnea or rapid respiration along with tachycardia and low blood pressure are present with severe dehydration. With severe dehydration, there will be decreased urine ouput. The body is trying to conserve volume. 3. Incorrect: The fontanels will be sunken rather than bulging. Bulging fontanels indicate brain swelling or fluid build up in the brain. Sunken fontanels are related to dehydration.)

The pediatric nurse is planning an educational seminar for new parents. The seminar will focus on tips for administering medication to children. Which points should the nurse include? Select all that apply 1. Demonstrate proper measuring techniques for liquid medications. 2. Put crushed medications into the child's favorite food. 3. Place liquid medication in an 8-ounce bottle of formula. 4. Call medication "candy" to encourage children to take the medicine. 5. Do not place medications in a container other than the original container.

1. Demonstrate proper measuring techniques for liquid medications. 5. Do not place medications in a container other than the original container. (1. & 5. Correct: Demonstration with return demonstration by the parent is an appropriate teaching strategy. Give clear examples and demonstrations and speak in layman's terms. Never put medications in dishes, cups, bottles, or other household containers that children or other family members may be unaware of. 2. Incorrect: Do not place crushed drugs into the child's favorite food or snack. The medication can change the taste of the food, and the child may refuse, therefore missing part or all of the dose. Additionally, the effectiveness of some medications may be harmed by the crushing of the drugs. 3. Incorrect: Do not place liquid drugs in a large bottle of formula. Unless the child drinks the entire amount, he or she will not receive the correct dose. 4. Incorrect: Don't refer to drugs as candy. Children may try to take more candy leading to overdose.)

The nurse is talking with a parent regarding childhood immunizations. What vaccination is recommended for children to receive at 6 months? Select all that apply 1. Diphtheria 2. Hib 3. Influenza 4. Measles 5. Mumps 6. Rubella

1. Diphtheria 2. Hib 3. Influenza (1., 2., & 3. Correct: In both the US and Canada, the third diphtheria vaccination is recommended at 6 months. The third Hib vaccine is also recommended in both countries at 6 months. Both countries also recommend that everyone 6 months of age and older get a flu vaccine each year. 4. Incorrect: The first measles vaccination is recommended at 12 months in Canada and between 12-18 months in the US. 5. Incorrect: The first mumps vaccination is recommended at 12 months in Canada and between 12-18 months in the US. 6. Incorrect: The first rubella vaccination is recommended at 12 months in Canada and between 12-18 months in the US.)

The nurse is discussing obesity prevention with a group of parents who have 3 and 4 year old children. What should the nurse include? Select all that apply 1. Ensure at least 11 hour of sleep. 2. Do not put a TV in the child's bedroom. 3. Select a day care center that provides physical activity opportunities every 4 hours. 4. Limit 100% fruit juice to 6 ounces (180 mL) per day. 5. Walk after the evening meal while the child rides a bike or skates.

1. Ensure at least 11 hour of sleep. 2. Do not put a TV in the child's bedroom. 4. Limit 100% fruit juice to 6 ounces (180 mL) per day. 5. Walk after the evening meal while the child rides a bike or skates. (1., 2., 4., & 5. Correct: Children between the ages of 2 and 5 should get between 11-12 hours of sleep each night. Keeping TVs out of bedrooms, creates an environment that promotes naps and nighttime sleep. Establishing sleep routines are all important to promoting healthy sleep habits. Fruit juice should be limited to 4-6 ounces (120-180 mL) per day, as excess consumption can lead to excess weight gain. Preschoolers should be encouraged to drink water. Role modeling behaviors such as exercise and doing it with the child encourages activity and decreases sedentary time. 3. Incorrect: The Institute of Medicine (IOM) stresses the importance of giving young children plenty of opportunity to be active during the day. Several states now require day care centers to provide the opportunity for at least two hours of physical activity during an eight-hour day. Selecting a day care that limits TV time and encourages play will promote a healthy lifestyle.)

A pediatric nurse is providing anticipatory guidance to a group of parents who have children nearing the age of 1 year old. What milestones should the nurse teach the parents to expect to see in their 1 year old child? Select all that apply 1. Gets to a standing position without help. 2. Puts out arm or leg to help with dressing. 3. Able to say several single words. 4. Pulls toys while walking. 5. Builds a tower of 4 blocks.

1. Gets to a standing position without help. 2. Puts out arm or leg to help with dressing. (1., & 2. Correct: A 1 year old should be able to get to a standing position without help. May stand alone. Can assist in getting dressed by putting out arm or leg. 3. Incorrect: Children at 18 months are able to say several single words. 4. Incorrect: Children at 18 months are able to pull toys while walking. 5. Incorrect: Children at 2 years of age can build a tower of 4 or more blocks.)

A 9 month old client is admitted to the hospital with a diagnosis of pertussis. Which interventions should the nurse initiate? Select all that apply 1. Initiate droplet precaution. 2. Place client under mist tent with low humidity. 3. Administer erythromycin 10 mg/kg/dose 4 times daily for 7 days. 4. Use client dedicated and disposable equipment. 5. Keep NPO.

1. Initiate droplet precaution. 3. Administer erythromycin 10 mg/kg/dose 4 times daily for 7 days. 4. Use client dedicated and disposable equipment. (1., 3., & 4. Correct: Pertussis is a very contagious disease that spreads from person to person by coughing or sneezing or when spending a lot of time near one another where you share breathing space. The nurse should place the child on droplet precautions in addition to standard precautions. For infants older than 1 month of age, macrolides drugs such as erythromycin are the drugs of choice. With droplet precautions you should use client dedicated or disposable equipment to prevent the spread of infection. If this is not possible, you must clean and disinfect shared/reusable equipment between use. This includes IV pumps, cell phones, pagers, other electronics, supplies, equipment. Clean prior to removing from the room. 2. Incorrect: A mist tent with high humidity may be used. The purpose is to improve a child's respiratory status by liquefying pulmonary secretions. 5. Incorrect: This child needs fluids, either by mouth or IV to keep from getting dehydrated, and to liquefy secretions.)

What developmental milestones does the nurse expect to see in a 9 month old infant? Select all that apply 1. Looks for fallen object. 2. Follows 1-step verbal command without gestures. 3. Plays peek-a-boo. 4. Understands the word "no". 5. Picks up cereal o's between the thumb and index finger. 6. Stands while holding on to something.

1. Looks for fallen object. 3. Plays peek-a-boo. 4. Understands the word "no". 5. Picks up cereal o's between the thumb and index finger. 6. Stands while holding on to something. (1., 3., 4., 5., & 6. Correct: When looking for the developmental milestones of a 9 month old, the nurse should expect to see the infant look for an object that has been dropped or that the infant sees someone hide. The infant can play simple games like peek-a-boo or itsy-bitsy spider. The word "no" should be understood by this age. Picking up things like cereal o's between the thumb and index finger is the pincer grasp that is achieved at this age. By nine months the infant should be able to pull self to a stand and stand while holding on to something. 2. Incorrect: The infant begins to follow simple directions like "pick up the toy" around the age of 1 year.)

A 6 year old admitted from the emergency department (ED) with a fractured tibia is scheduled for surgery in the morning. All of the private rooms are full so the child must be admitted to a semi-private room. What room assignment is appropriate for the nurse to make for this client? 1. Rooming with an 8 year old in sickle cell crisis. 2. Rooming with a 2 year old admitted with bacteremia. 3. Rooming with a 3 year old with pneumonia. 4. Rooming with a 4 year old with gastroenteritis.

1. Rooming with an 8 year old in sickle cell crisis. (1. Correct: Sickle cell disease and a child in a sickle cell crisis is not considered contagious. This is the only option that does not have an infectious process, so this would be the best room assignment for the child with the fracture. In addition, the children are close in age with the same development tasks, so activities for the children may be similar. 2. Incorrect: Bacteremia is an infectious process in which there is viable bacteria in the blood stream. The source of the infection is not noted. The child with a fracture who will be having surgery should not be placed in a room with a child who has a known infection. 3. Incorrect: The child with pneumonia has an infectious process that may be viral or bacterial. The child with the fracture should not be assigned to this room due to the risk of air-borne exposure to the infectious agent. 4. Incorrect: Gastroenteritis is a diarrheal illness with inflammation in the stomach and small intestine. This is contagious, so if all possible, this child should be kept in a private room, so other children would be less likely to contract the gastroenteritis. It may be viral, bacterial, or parasitic in origin. The child with the fracture should not be assigned to the room with the child with gastroenteritis.)

An 18 month old is admitted to the unit with a diagnosis of pertussis. The mother asks the nurse, "How did my child get this disease? I didn't think anyone got that anymore." What is the appropriate response by the nurse? 1. "Pertussis is a common childhood disease since there is no vaccine." 2. "Since not all children are immunized against pertussis, the disease has reemerged." 3. "Your baby got this disease because you didn't have your child immunized." 4. "Since your child is already sick, let's just focus on getting well."

2. "Since not all children are immunized against pertussis, the disease has reemerged." (2. Correct: This is a correct statement. Therapeutic communication means providing information that will help clients make better choices.Not all parents have had their children immunized against pertussis, so this disease is being seen in clients again. DPaT should be given at 2, 4 and 6 months of age. A booster is given at 15-18 months old and then at 4-6 years old. 1. Incorrect: This is not true. There is a vaccine. DPaT should be given at 2, 4, and 6 months of age. A booster is given at 15-18 months old and then at 4-6 years old. 3. Incorrect: Don't be confrontational. This puts the mother on the defensive. This is not therapeutic communication. Giving one's own opinion, evaluating, moralizing or implying one's values by using words such as "nice" "bad" "right" "wrong" "should" and "ought". "You shouldn't do that. It is wrong".​​ Everyone who does not get immunized gets the disease. 4. Incorrect: Do not change the subject. This does not address the mother's concern. Changing the subject, or introducing new topic inappropriately, can create anxiety. The nurse needs to address the mother's question of how the child contracted the disease.)

A child is being discharged home following a bone marrow transplant. When providing discharge instructions to the parents, what information is most important for the nurse to include? 1. Clean toothbrush weekly with alcohol. 2. Avoid eating raw fruits and vegetables. 3. Drink bottled water the day. 4. Apply heating pad to bruised areas of the skin.

2. Avoid eating raw fruits and vegetables. (2. Correct:The greatest risk to clients following a transplant is the chance of infection from any source since the client is severely immune-compromised for an extended period of time. There are numerous precautions necessary to avoid bacteria, but one area of concern is food storage, preparation, and consumption. Raw fruits with no skin to peel, such as strawberries, and raw vegetables like broccoli and cauliflower, present a serious risk for bacterial contamination and should not be consumed by new transplant clients. 1. Incorrect: Precise mouth care is vital following a bone marrow transplant; however, rinsing a toothbrush in alcohol is unsafe. Any residual alcohol would cause irritation and trauma to gum tissue, placing the client at risk for mouth inflammation and infection. Clients are instructed to brush teeth twice daily with a soft bristle brush, using a fluoride toothpaste. Some clients are instructed to soak the toothbrush once weekly in a special bleach solution, then rinse in hot water, while others need to replace the toothbrush weekly, based on lab test results. 3. Incorrect: Standing water of any type quickly builds up bacteria, including flower vases and vaporizers. Although bottled water may seem a safe choice, after that bottle is opened, bacteria begins to quickly build up, even if the bottle is recapped. Any water standing more than 15 minutes is considered old and must be thrown out. 4. Incorrect: With bone marrow transplant clients, it will be months before the body begins to stabilize and produce normal blood cells. Bruising and low platelet counts are to be expected for a period of time. When clients develop bruising, the approved treatment is cold compresses or ice packs applied for 15 minutes a couple times per day, and never a heating pad. Additionally, the healthcare provider should be notified so that a current platelet count can be obtained.)

A 13 year old found unresponsive in the park is brought into the emergency department (ED). The nurse sees a medical alert bracelet stating "Diabetic", and notes a fruity smell to the breath. There are no family members available to obtain consent for treatment and attempts to call them have been unsuccessful. What action should the nurse take? 1. Obtain consent from the social worker on duty in the emergency department. 2. Begin treatment by inserting two large bore IVs for administration of normal saline. 3. Give Glucagon IM and then wait for the arrival of a parent to consent to further treatment. 4. Notify the pirmary healthcare provider.

2. Begin treatment by inserting two large bore IVs for administration of normal saline. (2. Correct: Consent for a minor is not needed in the event of an emergency. Begin treatment for Diabetic Ketoacidosis (DKA). 1. Incorrect: Consent for a minor is not needed in the event of an emergency. The social worker does not give consent in this situation. 3. Incorrect: This client is exhibiting signs of DKA, so glucagon is not needed. Emergency treatment can be provided without parental consent for a minor. 4, Incorrect: The primary healthcare provider cannot give consent or treatment in the ED. The ED physician and nurses can provide treatment in an emergency.)

The nurse is talking with a group of teenagers who have expressed an interest in getting a tattoo. What information about tattoos should the nurse provide? Select all that apply 1. Apply a moisturizer to the tattooed skin once a day. 2. Carefully consider the tattoo location as weight gain can distort the image. 3. Bloodborne risks of tattooing include Hepatitis and HIV. 4. Tattoo dyes can cause allergic skin reactions. 5. Tattoos can be inexpensively removed with little discomfort. 6. Make sure the tattoo artist removes the needle and tubes from sealed packages.

2. Carefully consider the tattoo location as weight gain can distort the image. 3. Bloodborne risks of tattooing include Hepatitis and HIV. 4. Tattoo dyes can cause allergic skin reactions. 6. Make sure the tattoo artist removes the needle and tubes from sealed packages. (2., 3., 4., & 6. Correct: Weight gain, including pregnancy weight gain, might distort the tattoo or affect its appearance. If the equipment is contaminated with infected blood, the client can contract various bloodborne diseases, hepatitis B, hepatitis C, and HIV. Tattoo dyes, especially red, green, yellow and blue dyes, can cause allergic skin reactions, such as an itchy rash at the tattoo site. Make sure the tattoo artist removes the needle and tubes from sealed packages before the procedure begins. This decreases the risk of a bloodborne disease. 1. Incorrect: Apply a mild moisturizer to the tattooed skin several times a day. The tattoo needs to remain moist to prevent scab formation. 5. Incorrect: For most people, tattoos should be considered permanent. New procedures for removal are painful and expensive.)

A child diagnosed with AIDS is scheduled for grade school immunizations. Which immunizations are safe for the nurse to administer to the child? Select all that apply 1. MMR (measles, mumps, rubella) 2. DTaP (diphtheria, tetanus, pertussis) 3. VAR (varicella) 4. HiB (haemophilus influenza) 5. OPV (oral polio virus)

2. DTaP (diphtheria, tetanus, pertussis) 4. HiB (haemophilus influenza) (2 & 4. Correct: Children with AIDS are immunocompromised because of the HIV virus. Vaccines are crucial to provide protection against common childhood diseases. However, only vaccines which contain synthetic or inactivated viral components are acceptable for children with active AIDS. Diphtheria, tetanus, pertussis is inactive and is provided in multiple doses, starting at 2 months of age, with a booster at age 6. Haemophilus influenza is critically important since this flu virus can lead to meningitis, pneumonia or epiglottitis. This vaccine is also administered in multiple injections over a period of months, starting at 2 months, and then yearly throughout life. 1. Incorrect: The combination vaccine of measles, mumps, and rubella contains a live virus. Although research is ongoing, the Center for Disease Control (CDC) suggests while children diagnosed HIV+ may receive the vaccine, those with active AIDS should not be administered this vaccine. 3. Incorrect: Varicella is a live vaccine administered to protect children from chickenpox and the potential for shingles later in life. Though the disease and its dormancy in the body can have serious long-term effects, the vaccine is considered inappropriate for children with AIDS. 5. Incorrect: Oral polio vaccine contains the live polio virus and could be deadly to those with an immunocompromised system. The correct form of polio vaccine for AIDS clients is called IPV, or inactivated polio vaccine, and is given by injection.)

The nurse is discussing appropriate toys for toddlers with a group of parents. What toys should the nurse include? Select all that apply 1. Board games 2. Finger paint 3. Swing set 4. Water squirting toys 5. Play telephone 6. Wooden spoons

2. Finger paint 4. Water squirting toys 5. Play telephone 6. Wooden spoons (2., 4., 5., & 6. Correct: Finger painting, water squirting toys, play phones, and wooden spoons are appropriate toys for the toddler. 1. Incorrect: Simple board games are appropriate for the preschooler. It is too soon to introduce board games to a toddler. 3. Incorrect: A swing set is appropriate for the preschooler if they are supervised.)

What interventions should the nurse plan to implement when admitting a client diagnosed with measles? Select all that apply 1. Admit to a semi-private room with a client diagnosed with tuberculosis (TB). 2. Place a surgical mask on the client when transferring to x-ray. 3. Initiate airborne precautions. 4. Wear surgical mask when entering the client's room. 5. Assign a nurse who has received the measles vaccine to take care of this client.

2. Place a surgical mask on the client when transferring to x-ray. 3. Initiate airborne precautions. 5. Assign a nurse who has received the measles vaccine to take care of this client. (2., 3., & 5. Correct: If the client must leave the room, a surgical mask should be worn to prevent transmission to others. Measles can be transmitted via contact, droplet, and airborne methods, so airborne precautions are needed. Healthcare providers who are not immune to measles should not care for a client with measles. 1. Incorrect: The client should be placed in a private room with negative air pressure when airborne precautions are necessary. TB and measles are not like illnesses and should not be placed in the same room. 4. Incorrect: A particulate or N95 respirators should be worn by staff entering the room of a client on airborne precautions. N95 respirators filter particles that you may inhale. A surgical mask prevents the spread of particles during exhalations.)

The nurse is providing care to a 5 year old client who has been experiencing moderate pain. Which intervention is appropriate for the nurse to use with this client? 1. Encourage the client to talk about the pain. 2. Provide distraction by turning on the TV. 3. Contact the primary healthcare provider for a pain medication prescription. 4. Request that the parents leave the room.

2. Provide distraction by turning on the TV. (2. Correct: Distraction is a good technique to use with the toddler/preschooler. Other distractions might be to read a book, or look at pictures. Heat and cold therapies should also be considered. 1. Incorrect: The client at this age does not have the cognitive abilities to discuss pain other than to say that he/she has pain and to tell where it is. They can rate their pain at age 5-8 but describing or qualifying pain occurs at age 10 and older. 3. Incorrect: Distraction and other techniques should be used before pain medication. If there is something you can do to fix the problem, do that first. 4. Incorrect: Separation from the parents could cause more anxiety for the child. Parents should be allowed to stay with the client unless they are hindering safe care.)

What developmental milestone does the nurse expect to see in a four month old baby? Select all that apply 1. Responds to own name. 2. Pushes up to elbows, when lying on stomach. 3. Rolls over from stomach to back. 4. Pushes down on legs when feet are on a hard surface. 5. Watches the path of something as it falls. 6. Reaches for toy with one hand.

2. Pushes up to elbows, when lying on stomach. 3. Rolls over from stomach to back. 4. Pushes down on legs when feet are on a hard surface. 6. Reaches for toy with one hand. (2., 3., 4., & 6. Correct: By the age of four months, the nurse would expect the baby to be able to push up to the elbows when lying prone. A baby may be able to roll over from abdomen to back by 4 months. At 4 months the baby should be able to push down on legs when feet are on a hard surface. Reaching for a toy with one hand is seen when the baby is 4 months of age. 1. Incorrect: A baby can respond to their own name by 6 months, not 4 months. 5. Incorrect: When checking the developmental milestones of a 9 month old, the nurse should expect to see the baby watch the path of something as it falls.)

The nurse is working on health promotion plans for a small group of school-aged children who are at risk for obesity. Which baseline data would support the risk for obesity? 1. Spends one hour playing sports or swimming daily. 2. Spends at least two hours watching TV after dinner each day. 3. Assists mom in preparing low carb snacks for the family. 4. Participates in the marching band at school.

2. Spends at least two hours watching TV after dinner each day. (2. Correct: Sedentary activities, such as watching television, playing video games and using a computer to surf the internet or engage with friends can also contribute to obesity and cardiovascular health problems in later life. 1. Incorrect: The more active the child is, the less likely he is to be overweight. Activity for at least one or more hours per day should be encouraged. 3. Incorrect: Children who are exposed to healthy snacks are less likely to be overweight and are more likely to choose healthy snacks. 4. Incorrect: The marching band is an excellent source of exercise for the child. This information does not support the risk for obesity.)

A new nurse is preparing to give a medication to a nine month old client. After checking a drug reference book, crushing the tablet and mixing it into 3 ounces of applesauce, the new nurse proceeds to the client's room. What priority action should the supervising nurse take? 1. Tell the new nurse to recheck the drug reference book before administering the medication. 2. Suggest the new nurse reconsider the client's developmental needs. 3. Check the prescription order and the client dose. 4. Observe the new nurse administer the medication.

2. Suggest the new nurse reconsider the client's developmental needs. (2. Correct. Mixing medication with applesauce is appropriate in some circumstances, but the volume of 3 ounces is excessive for a nine month old. The nurse will want to make sure the client gets all of the medication. Additionally, applesauce may or may not have been introduced into the diet, and it is inappropriate to introduce a new food during an illness. 1. Incorrect. There is nothing in the stem about a problem with the medication dose or route. The drug reference book does not provide guidelines for meeting developmental needs when administering the medication. This is something that the nurse must look up if uncertain about developmental tasks. 3. Incorrect. There is nothing in the stem about a problem with the medication dose or route. Once the medication has been mixed in applesauce, the supervising nurse would not be able to compare the dose to the prescribed amount. Therefore, this would not be an appropriate action. It would not address the developmental task that is the underlying issue here. 4. Incorrect. This is an appropriate action. However, it is not the priority. The new nurse should be competent in medication administration but is needing guidance with the developmental considerations related to medication to a nine month old.)

The home care nurse, working with an infant in the home, is concerned about the infant developing diaper rash from wearing cloth diapers. Which strategies should the nurse teach to the parents to prevent skin irritation? Select all that apply 1. Change diapers every four hours. 2. Wash diapers with hypoallergenic detergent. 3. Rinse diapers twice when washing. 4. Apply a protective ointment to diaper area with each diaper change. 5. Check infant at least hourly for wet or soiled diapers.

2. Wash diapers with hypoallergenic detergent. 3. Rinse diapers twice when washing. 4. Apply a protective ointment to diaper area with each diaper change. 5. Check infant at least hourly for wet or soiled diapers. (2., 3., 4. & 5. Correct: Hypoallergenic detergent will remove skin bacteria as well as urine from the diaper. Detergents can be irritating to the skin and may cause dryness; therefore, adequate rinsing is important. Double rinse the diapers in cold water to remove traces of chemicals and soap. A protective ointment is even more important to use with cloth diapers, as they do not have the same wicking properties of the disposable diapers. Frequently checking the diaper for wetness and soiling will limit the contact time for urine or feces to be in contact with the skin. Whether using cloth diapers, disposables or both kinds, always change the baby as soon as possible after wetting or soiling the diaper to keep the bottom as clean and dry as possible. 1. Incorrect: The child should be checked more frequently to prevent irritation to the skin from soiling. At least every 2 hours is recommended.)

A child presents to the school nurse with left knee pain after suffering a fall on the playground. Which action should the nurse initiate? 1. Instruct the child to extend the affected knee 2. Perform range of motion exercise on both knees 3. Compare the appearance of the left knee to the right knee 4. Have the child soak the affected knee in warm water

3. Compare the appearance of the left knee to the right knee (3. Correct: Comparing the appearance of the left knee to the right knee is the least invasive assessment and allows the nurse to assess if there is a change in the appearance of the affected knee to the unaffected knee. 1. Incorrect: The extent of the injury is not known until after an assessment is done. Remember the nursing process here. Assess first. Extending the affected knee may cause further damage. 2. Incorrect: You don't want the child to move the extremity prior to assess for broken bones. Range of motion exercises may cause further damage to the affected knee. 4. Incorrect: Soaking the affected knee in warm water will not help the nurse assess whether or not an injury occurred.)

A nurse is attempting to assess lung sounds on a 3 year old with a history of asthma. Which indicates the best method to encourage the hospitalized child to take a deep breath? 1. Allow the child to blow out a lighted candle. 2. Encourage child to blow bubbles from a wand. 3. Teach child to blow cotton balls off the table. 4. Instruct child on using an incentive spirometer.

3. Teach child to blow cotton balls off the table. (3. Correct: Assessing lung sounds requires a client to inhale and exhale while the nurse auscultates. The most efficient method is to have the child participate in a game that requires breathing in and out. Blowing a cotton ball across a table is an appropriate activity which can be easily understood by a 3 year old child and mimics a game that will encourage participation. 1. Incorrect: An open flame, even on a small candle, is a safety violation and contraindicated in all types of health facilities. Additionally, since the child will need to breathe in and out multiple times, it would be both risky and inconvenient to keep relighting a candle. 2. Incorrect: While it might be easier, and even enjoyable, for the child try to blow bubbles from a bubble wand, consider the safety aspect. Bubbles are made from soap, which would make floors slippery. Additionally, children usually want to chase bubbles, and having the child remain still for auscultation would be a challenge. 4. Incorrect: The purpose of using an incentive spirometer is to encourage clients to cough and deep breath. Instructing a 3 year old on the spirometer would be challenging and does not help the nurse to assess lung sounds.)

A nurse is triaging a 2 year old child in the pediatric emergency department. The nurse notes that the child will not lie down and is consistently drooling. A croaking sound is heard on inspiration. What is the priority nursing intervention? 1. Examine the oral pharynx using a tongue depressor. 2. Administer a sedative so the child can be examined. 3. Have a second nurse hold the child down for the assessment. 4. Notify the primary healthcare provider immediately.

4. Notify the primary healthcare provider immediately. (4. Correct: This is the safest answer. The child could suddenly obstruct the airway upon examination of throat. 1. Incorrect: If it looks like epiglottitis, do not examine as this could cause sudden airway obstruction which could be fatal. 2. Incorrect: The client is having trouble breathing, so do not sedate the client. Sedatives would depress the respirations more and potentially cause the client to go into respiratory arrest. Remember, the NCLEX® lady does not want you to be a killer nurse. 3. Incorrect: This will cause more respiratory and emotional distress to the child. This is an unsafe answer.)