NCLEX-PN CARDIAC PEDIATRIC

The nurse caring for an infant with congenital heart disease is monitoring the infant closely for signs of heart failure (HF). The nurse should observe for which early sign of HF? Select all that apply.

Irritability Scalp diaphoresis Tachypnea, tachycardia

The nurse is caring for a child with a diagnosis of Kawasaki disease. The mother of the child asks the nurse about the disorder. Which statement by the nurse most accurately describes Kawasaki disease?

It is also called mucocutaneous lymph node syndrome and is a febrile generalized vasculitis of unknown cause.

The nurse is caring for a 9-year-old child with leukemia who is hospitalized for the administration of chemotherapy. The nurse monitors the child for central nervous system (CNS) involvement by checking which response?

Level of consciousness (LOC)

A 4-year-old child with acute lymphocytic leukemia has been admitted to the hospital in relapse. The priority concern is infection due to immunosuppression. Which interventions should the nurse include in the plan of care?

Perform oral hygiene four times a day.

A 5-year-old child is admitted to the hospital for heart surgery to repair tetralogy of Fallot. The nurse notes that the child has clubbed fingers, and the nurse knows that this symptom is likely a result of which condition?

Peripheral hypoxia

The nurse was caring for an infant who had come to the nursing unit for observation and treatment of tetralogy of Fallot. The child suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. The nurse should perform which action first?

Place the child in a knee-chest position.

Blood cultures

Heart failure (HF)

The nurse assists with admitting a child with a diagnosis of acute stage Kawasaki disease. When obtaining the child's medical history, which manifestation is likely to be noted?

Conjunctival hyperemia

The nurse reinforces instructions to the parents of a child with leukemia regarding measures related to monitoring for infection. Which statement by the parents indicates the need for further teaching?

"I need to take my child's rectal temperature daily."

The nurse is providing discharge instructions to the parents of a 14-year-old child who is undergoing radiation for Hodgkin's disease. Which statement by a parent indicates the need for further teaching?

"I will need to keep my child's skin from flaking, so we will be allowing showers every 2 or 3 days."

The nurse is caring for a mother and her infant who was born 12 hours ago. Which statements made by the mother should prompt the nurse to have the baby evaluated for early heart failure? Select all that apply.

"I'm chilly but my baby's forehead is sweaty." "I can feel my baby's heart rate when he's sleeping, it seems much faster than it did yesterday." "My baby latches on to my nipple well and has a strong suck, but seems to get weak very quickly, then stops too soon."

The nurse is monitoring the laboratory values of a child with leukemia who is receiving chemotherapy. The nurse prepares to implement bleeding precautions if the child becomes thrombocytopenic and the platelet count is less than which value?

20,000 mm3

A nursing student is assigned to care for an infant with a diagnosis of heart failure (HF). The student develops a plan of care for the child that is focused on monitoring for fluid overload. The student plans to best assess the urine output of the infant by taking which action?

Weighing the diapers

A 4-year-old child is admitted to the hospital with suspected acute lymphocytic leukemia (ALL). The nurse should prepare for which diagnostic study that can confirm this diagnosis?

A bone marrow biopsy

The nurse is caring for a child with osteosarcoma following amputation of the left lower limb. The child is continually complaining of aching and cramping in the missing limb. Which action should the nurse take?

Reassure the child that this is a temporary condition.

A nursing student is asked to discuss the pathophysiology related to childhood leukemia during a clinical conference and reviews the planned presentation with the nursing instructor. The nursing instructor advises the student to review the disorder before the clinical conference if the student states that which is associated with this type of cancer?

Reed-Sternberg cells are found on biopsy.

A 12-year-old child is seen in the clinic, and a diagnosis of Hodgkin's disease is suspected. Several diagnostic studies are performed to determine the presence of this disease. When evaluating the diagnostic results, the nurse should expect to note which evidence if this child has Hodgkin's disease?

The presence of Reed-Sternberg cells

The nursing instructor assigns a student nurse to present a clinical conference to the student group about brain tumors in children. Which statement by the student is accurate about brain tumors in children?

The significant symptoms are headaches and morning vomiting.

The nurse is monitoring the daily weight of an infant with heart failure (HF). Which finding alerts the nurse to suspect fluid accumulation and thus the need to notify the registered nurse?

A weight gain of 1 lb in 1 day

The nurse is assisting in preparing to care for a child with a brain tumor who will be returning from the recovery room following debulking of the tumor. Which item should the nurse place at the bedside in preparation for the child's return from surgery?

A cooling blanket

The nurse is collecting data on a child with a diagnosis of rheumatic fever. Which question should the nurse initially ask the mother of the child?

"Has the child complained of a sore throat within the past few months?"

The nurse is told that a child with rheumatic fever (RF) will be arriving to the nursing unit for admission. Which question should the nurse ask the family to elicit information specific to the development of RF?

"Has the child had a sore throat or a fever within the past 2 months?"

The nurse has reinforced homecare instructions to the parent of a child who is being discharged after cardiac surgery. Which statement by the parent indicates the need for further teaching?

"I can apply lotion or powder to the incision if it is itchy."

The nurse is providing instructions to a parent of a child with patent ductus arteriosus (PDA). Which statement by the parent would indicate a need for further teaching?

"I know that my child will outgrow this problem, just give him time."

The nurse provides homecare instructions to the parents of a child with heart failure regarding the procedure for the administration of digoxin. Which statement by a parent indicates the need for further teaching?

"If my child vomits after medication administration, I will repeat the dose."

The nursing instructor asks a student nurse to describe osteogenic sarcoma. Which statement by the student indicates the need to further research the disease?

"The child does not experience pain at the primary tumor site."

The nurse is assigned to care for a child with a diagnosis of Wilms' tumor. The child's mother asks the nurse what kind of tumor this is. What is the best response by the nurse?

A nephroblastoma

A preliminary diagnosis is made for a child with acute lymphoblastic leukemia (ALL). In reviewing the complete blood cell count (CBC) of the child, the nurse should expect to find which?

An erythrocyte (red blood cell) count of 2 cells in 1 mL of peripheral blood

The nurse is caring for a child with a suspected diagnosis of rheumatic fever (RF). The nurse reviews the laboratory results. Which laboratory study should assist in confirming the diagnosis of RF?

Antistreptolysin O titer

A 5-year-old child has been transferred to the pediatric unit after a cardiac catheterization. Which intervention has the highest priority in the care of this child immediately following the procedure?

Assess for any bleeding on the dressing.

The nurse is assigned to care for a child admitted to the hospital with a diagnosis of suspected bacterial endocarditis. The nurse prepares the child for which diagnostic test that will confirm the diagnosis?

Blood cultures

The nurse is assessing a pediatric client with a diagnosis of retinoblastoma. The nurse assesses for which most common clinical finding for a child with this diagnosis?

Cat's-eye reflex

The nurse has reviewed the primary health care provider's prescriptions for a child suspected of a diagnosis of neuroblastoma and is preparing to implement diagnostic procedures that will confirm the diagnosis. The nurse prepares to do which?

Collect a 24-hour urine sample.

The nurse is reviewing the primary health care provider's prescriptions for a child with rheumatic fever who is suspected of having a viral infection. The nurse notes that acetylsalicylic acid is prescribed for the child. Which nursing action is appropriate?

Consult with the registered nurse to verify the prescription.

A child is admitted to the pediatric unit with a diagnosis of coarctation of the aorta (COA). The primary health care provider prescribes that the child's blood pressure be taken every 4 hours in the legs and arms. The nurse should expect which blood pressure readings in the child's legs and arms?

Decreased in the legs and increased in the arms

The nurse is caring for an infant with congenital heart disease. Which signs, if noted in the infant, should alert the nurse to the early development of heart failure (HF)?

Diaphoresis

The nurse reviews the record of a child who was just seen by the primary health care provider (PHCP). The PHCP has documented a diagnosis of suspected aortic stenosis. Which specific sign/symptom of aortic stenosis should the nurse anticipate?

Exercise intolerance

The nurse monitors a 5-year-old child admitted to the hospital for a neuroblastoma for signs and symptoms related to the location of the tumor in the adrenal gland. Which descriptions would the nurse expect to be documented in the child's record specific to this tumor? Select all that apply.

Firm, nontender, irregular mass in the abdomen Urinary frequency or retention from compression on the bladder

The nurse is reviewing a primary health care provider's prescription for a child who was just admitted to the hospital with a diagnosis of Kawasaki disease. Which prescription should the nurse anticipate being part of the treatment plan?

Immune globulin

The nurse is preparing to care for a child who received an allogenic bone marrow transplant (BMT). The nurse understands that which is the priority concern?

Infection

The nurse is asked to prepare for the admission of a child to the pediatric unit with a diagnosis of Wilms' tumor. The nurse assists in developing a plan of care for the child and suggests including which intervention in the plan of care?

Inspect the urine for the presence of hematuria at each voiding.

The nurse is monitoring for bleeding in a child after surgery to remove a brain tumor. The nurse checks the head dressing for the presence of blood and notes a colorless drainage on the back of the dressing. Which nursing action is appropriate?

Notify the registered nurse (RN).

The nurse is reinforcing discharge teaching to the parents of an infant diagnosed with tetralogy of Fallot. Which statements made by the parents indicate a need for further teaching? Select all that apply.

Our child will eventually grow out of this condition. It is not necessary to avoid individuals with the common cold.

A 4-year-old child is hospitalized with a suspected diagnosis of Wilms' tumor. The nurse reviews the plan of care and should question which intervention that is written in the plan?

Palpate the abdomen for a mass.

Prostaglandin E1 is prescribed for a child with transposition of the great arteries. The parent of the child asks the nurse why the child needs the medication. The nurse correctly responds that the purpose of this medication is which explanation?

Provides adequate oxygen saturation and maintains cardiac output

A health care provider has prescribed oxygen as needed for a 10-month-old infant with heart failure (HF). In which situation should the nurse administer the oxygen to the child?

When drawing blood for electrolyte levels

The nurse is preparing to administer digoxin to an infant with heart failure (HF). Before administering the medication, the nurse double-checks the dose, counts the apical heart rate for 1 full minute, and obtains a rate of 88 beats per minute. Based on this finding, which is the appropriate nursing action?

Withhold the medication.

A 6-year-old child has just been diagnosed with localized Hodgkin's disease, and chemotherapy is planned to begin immediately. The mother of the child asks the nurse about radiation therapy because it was not prescribed as a part of treatment. Which is the most appropriateresponse to the mother?

"The child is too young to have radiation therapy."

A nursing instructor asks a student nurse assigned to care for an infant with a diagnosis of tricuspid atresia to describe the infant's disorder. Which statement by the student indicates the need to further research this disorder?

"The disorder means there is no communication from the right atrium to the right ventricle of the heart."

A 6-year-old child with leukemia is hospitalized and is receiving combination chemotherapy. Laboratory results indicate that the child is neutropenic, and the nurse prepares to implement protective isolation procedures. Which interventions should the nurse initiate? Select all that apply.

Place the child on a low-bacteria diet. Change dressings using sterile technique. Perform meticulous hand washing before caring for the child.

The client presents to the pediatrician's office with a temperature of 103° F for the past 3 days. The nurse also observes conjunctivitis without discharge, cracked lips, enlarged reddened papilla on the tongue, inflamed oropharyngeal membranes, and enlarged nontender lymph nodes. Using situation, background, assessment, and recommendation (SBAR communication), which statements and/or questions should the nurse use in communication with the primary health care provider regarding this client's condition? Select all that apply.

"I am concerned this client has Kawasaki's disease. Can you please come assess this client?" "This client is a 4-year-old male who presented to the clinic with a temperature of 103° F for the past 3 days." "I think this client is at risk for aneurysm and thrombi development and should be taken to the hospital immediately." "I observed this client to have conjunctivitis without discharge, cracked lips, enlarged reddened papilla on the tongue, inflamed oropharyngeal membranes, and enlarged nontender lymph nodes."

The nurse is assigned to care for an infant with tetralogy of Fallot. The mother of the infant calls the nurse to the room because the infant suddenly seems to be having difficulty breathing. The nurse enters the room and notes that the infant is experiencing a hypercyanotic episode. Which action should the nurse take?

Place the infant in a knee-chest position.