NCLEX-RN (CHILDREN GI/RESPIRATORY)
The nurse is caring for an infant diagnosed with Hirschsprung disease who is awaiting surgery. Which assessment finding requires the nurse's immediate action? 1. Abdominal distention with no change in girth for 8 hours 2. Did not pass meconium or stool within 48 hours after birth 3. Episode of foul-smelling diarrhea and fever 4. Excessive crying and greenish vomiting
3. Episode of foul-smelling diarrhea and fever
The nurse is assisting with an education conference for graduate nurses about infant CPR. Which of the following statements are appropriate to include in the teaching? SATA 1. A single rescuer responding to an unwitnessed infant arrest should perform 2 minutes of CPR before retrieving a defibrillator 2. Depth of chest compressions for infants should be half the depth of the anterior posterior chest diameter 3. Rescuers should place the heel of one hand on the lower sternum when delivering chest compressions to infants 4. The ratio of chest compressions to breaths during CPR by a single rescuer is 15:2 for infants 5. You should assess the infant's brachial pulse for not longer than 10 seconds
1. A single rescuer responding to an unwitnessed infant arrest should perform 2 minutes of CPR before retrieving a defibrillator 5. You should assess the infant's brachial pulse for not longer than 10 seconds **The rescuer should check the infant's brachial pulse for no longer than 10 seconds. During an unwitnessed collapse, a single rescuer should shout for help, activate emergency response and provide 2 minutes of CPR. **A single rescuer CPR is 30:2 and a two rescuer provides 15:2 (compression to breath ratio)
The nurse cares for a child newly diagnosed with cystic fibrosis. What should be included in the client's multidisciplinary plan of care to be discussed with the parents? SATA 1. Aerobic exercise 2. Chest physiotherapy 3. Financial needs 4. Low calorie diet 5. Oral fluid restriction
1. Aerobic exercise 2. Chest physiotherapy 3. Financial needs
A 12 month old client has a high blood lead level of 18 mcg/dL. The nurse educates the parents about lead poisoning. Which statements made by the parent indicate that teaching is successful? SATA 1. I should get our home inspected for the source of the lead 2. I will vacuum our hard surface floors faily 3. I will wash my child's hands often, especially before eating 4. We should use hot tap water for cooking 5. We will have to return for a follow up lead level
1. I should get our home inspected for the source of the lead 3. I will wash my child's hands often, especially before eating 5. We will have to return for a follow up lead level Pediatric clients are at risk for lead poisoning from environmental exposure in the home (pain, dust, plumbing) **Lead sources in the home should be removed or mitigated (handwashing, wet-dusting/mopping)
The nurse is reviewing discharge instructions with the parents of child who just had a tracheostomy. Which statement made by the parents indicates teaching has been effective? 1. I will always travel with two tracheostomy tubes, one of the same size and one a size smaller 2. I will immediately change the tracheostomy tube if my child has difficulty breathing 3. I will provide deep suctioning frequently to prevent any airway obstruction 4. I will remove the humidifier if my child starts developing more secretions
1. I will always travel with two tracheostomy tubes, one of the same size and one a size smaller
The nurse is gathering data on a 5 week old admitted with a suspected diagnosis of pyloric stenosis. The nurse should expect to find which lab value? 1. Blood pH of 7.1 2. Hematocrit of 57% 3. Potassium of 5.2 4. WBC of 28,000
2. Hematocrit of 57% **Hypertrophic pyloric stenosis results from projectile vomiting which leads to dehydration and metabolic alkalosis.
The nurse is caring for a newborn with patent ductus arteriosus. Which assessment finding should the nurse expect? 1. Harsh systolic murmur 2. Loud machine like murmur 3. Soft diastolic murmur 4. Systolic ejection murmur
2. Loud machine like murmur **Patient ductus arteriosus (PDA) is an acyanotic congenital defect commonly found in premature infants. **It can be treated with surgical ligation or an IV indomethacin to stimulate duct closure.
The nurse is planning care for a child being admitted with Kawasaki disease and should give priority to which nursing intervention? 1. Apply cool compresses to the skin of the hands and feet 2. Monitor for a gallop heart rhythm and decreased urine output 3. Prepare a quiet, non-stimulating and restful environment 4. Provide soft foods and liberal amounts of clear liquids
2. Monitor for a gallop heart rhythm and decreased urine output **Kawasaki disease is a childhood condition that causes inflammation of arterial walls (vasculitis) **The treatment consists of aspirin and infusion of IV gamma globulin. The affected child must be monitored for signs of heart failure.
When monitoring an infant with a left to right sided heart shunt, which findings would the nurse expect during the physical assessment? SATA 1. Clubbing of fingertips 2. Cyanosis when crying 3. Diaphoresis when crying 4. Heart murmur 5. Poor weight gain
3. Diaphoresis when crying 4. Heart murmur 5. Poor weight gain **Left to right shunting results in pulmonary congestion, causing an increase work of breathing and decreased lung compliance. Infant will feel heart murmur, poor weight gain, diaphoresis with exertion, and signs of heart failure
The nurse receives change of shift report on 4 clients. Which client should the nurse assess first? 1. 6 month old with respiratory syncytial virus and pulse oximetry of 90% 2. 1 year old with otitis media and a temperature of 102.5 3. 2 year old with suspected epiglottitis 4. 3 year old who has a barking type cough
3. 2 year old with suspected epiglottitis **Epiglottitis is a sudden medical emergency that causes severe inflammatory obstruction above and around the glottis. **Sitting in a tripod position (upright and leaning forward with chin and tongue sticking out is classic) the child will drool and be restless/anxious to airway obstruction and hypoxia.
In the emergency department, a pediatric client is placed on mechanical ventilation by means of an endotracheal tube. Several hours later, the nurse enters the room and finds the client in respiratory distress. It is most important for the nurse to take which of these actions? 1. Assess the client for intercostal retractions 2. Assess the client's blood pressure in both arms 3. Auscultate the client's lung sounds 4. Observe the color of the client's fingernail beds
3. Auscultate the client's lung sounds **Doing this assessment will determine if mechanical ventilation equipment is still properly placed in the trachea. The endotracheal tube can become displaced with movement.
The parent of a 7 month old reports that the child has been crying and vomiting with a distended belly for the past 4 hours. The infant is now lying quietly in the parent's arm with a pulse of 200/min and respirations of 60/min. Which of the following components of SBAR (Situation, Background, Assessment, Recommendation/Readback) communication is most important for the nurse to report to the healthcare provider? 1. Client has been ill for approximately 4 hours 2. Client has improved from apparent earlier distress 3. Client is now lethargic with abnormal vital signs 4. Does the healthcare provider want to order a laxative
3. Client is now lethargic with abnormal vital signs
During a routine assessment of a developmentally normal 18 month old, the parent expresses concern about the small amount of food the child consumes. What is the nurse's priority intervention? 1. Check the child for parasitic infections 2. Consult a pediatric nutritionist for suspected eating disorder 3. Educate the parent about physiologic anorexia 4. Notify the primary healthcare provider
3. Educate the parent about physiologic anorexia
A nurse is evaluating a client's understanding about infant formula preparation. Which of the following client statements indicate proper understanding? SATA 1. I can add extra water to powdered formula if it seems that my baby wants to feed longer 2. I can heat formula in the microwave for less than 1 minute 3. I must wash the top of concentrated formula cans before opening 4. Leftover milk in the bottle may be refrigerated and used at a later feeding 5. Unused, prepared formula should be kept in the refrigerator and discarded after 48 hours
3. I must wash the top of concentrated formula cans before opening 5. Unused, prepared formula should be kept in the refrigerator and discarded after 48 hours **Never microwave formula, it can cause "hot spots" in the milk and can burn the infant's mouth. **Formula left over in a bottle after a feeding should be discarded. **Unused, prepared formula should be stored in the refrigerator and if unused discarded after 48 hours.
The nurse assesses a child who has been treated for an acute asthma exacerbation. Which client assessment is the best indicator that treatment has been effective? 1. Episodes of spasmodic coughing have decreased 2. No wheezes are audible on chest auscultation 3. Oxygen saturation has increased from 88% to 93% 4. Peak expiratory flow rate has dropped from 212 L/min to 127 L/min
3. Oxygen saturation has increased from 88% to 93%
A nurse in the neonatal intensive care unit discovers a cyanotic newborn with excessive frothy mucus in the mouth. What should be the nurse's first action? 1. Administer 100% oxygen 2. Auscultate the lungs 3. Place infant in knee to chest position 4. Suction the infant's mouth
4. Suction the infant's mouth **Excessive frothy mucus and cyanosis in a newborn could be due to esophageal atresia and tracheoesophageal fistula. If suspected the infant should be kept supine with the head elevated at least 30 degrees to prevent aspiration.
A 3 month old infant has irritability, facial edema, a 1 day history of diarrhea with adequate oral intake and seizure activity. During assessment, the parents state that they have recently been diluting formula to save money. Which is the most likely cause for the infant's symptoms? 1. Hypernatremia due to diarrhea 2. Hypoglycemia due to dilute formula intake 3. Hypokalemia due to excess gastrointestinal output 4. Hyponatremia due to water intoxication
4. Hyponatremia due to water intoxication **Infants have an immature renal system with low molecular infiltration rate which decreases their ability to excrete excess water. **Breast milk/formula are only sources of hydration the infant needs for the first 6 months of life.
A nurse is assessing a new mother as she is breastfeeding her infant. The infant has been diagnosed with Tetralogy of Fallot. During feeding, the infant becomes cyanotic and is having difficulty breathing. What should be the nurses's first action? 1. Administer morphine to the infant 2. Administer oxygen via mask 3. Assess infant's vital signs and pulse oximetry 4. Place the infant in the knee-chest position
4. Place the infant in the knee-chest position **To relieve a hypercyanotic episode or "tet" spell, the nurse should place the infant in the knee-chest position
A 2 year old child is brought to the emergency department for a severe sore throat and fever of 102.9. The nurse notes that the child is drooling with distressed respirations and inspiratory stridor. What action should the nurse take first? 1. Assess an accurate temperature with a rectal thermometer 2. Directly examine the throat for the presence of exudates 3. Obtain IV access for anticipated steroid administration 4. Position the child in tripod position on the parent's lap
4. Position the child in tripod position on the parent's lap **Epiglottitis is an inflammation by bacteria of the tissues surrounding the epiglottis, a long, narrow structure that closes off the glottis during swallowing. **Children with epiglottitis should be allowed a position of comfort without any invasive or anxiety provoking procedures (phlebotomy, pharyngeal examination, epiglottal cultures) until the airway is secure with intubation or a surgical airway.
The nurse is teaching a class on nutrition and feeding practices for young children. What should the nurse recommend as the best snack for a toddler? 1. 1/2 cup orange juice 2. Dry, sweetened cereal 3. Raw carrot sticks 4. Slices of cheese
4. Slices of cheese **Healthy snacks for toddlers are pieces of cheese, whole wheat crackers, banana slices, yogurt, cooked vegetables and cottage cheese
A 9 year old has terminal cancer, but the parents do not want the child to know the prognosis. The child has been asking questions such as what dying is like and whether the child will die. Which action by the nurse is most appropriate? 1. Encourage the child to ask the parents these questions 2. Notify the HCP about the child's questions 3. Reassure the child that everyone is trying to help the child get better 4. Tell the parents about the child's questions
4. Tell the parents about the child's questions
A nurse in a clinic is talking with a parent about the onset of puberty in boys. What is the first sign of pubertal change that occurs? 1. Appearance of upper lip hair 2. Increase in height 3. Presence of axillary hair 4. Testicular enlargement
4. Testicular enlargement **Testicular enlargement is the first manifestation of puberty and sexual maturation. It occurs at age 9 1/2-14 years old. After the enlargement comes the appearance of pubic, axillary, facial and body hair. The penis increases in size and the voice changes.
The nurse in a clinic is caring for an 8 month old with a new diagnosis of bronchiolitis due to respiratory syncytial virus (RSV). Which instructions can the nurse anticipate reviewing with the parent? 1. Administering a cough suppressant and antihistamine 2. Prophylactic treatment of family members 3. Temporary cessation of breastfeeding 4. Use of saline drops and a bulb syringe to suction nares
4. Use of saline drops and a bulb syringe to suction nares **Bronchiolitis is a viral illness caused by RSV. Parents should be instructed to use saline nose drops and then suction the nares with bulb syringe to remove secretions prior to feedings and at bedtime.
The nurse is reinforcing discharge teaching for the parents of a 1 year old with a newly diagnosed cow's milk allergy. Which nutrients normally provided by milk should be obtained from other sources? SATA 1. Calcium 2. Fiber 3. Iron 4. Vitamin D 5. Vitamin K
1. Calcium 4. Vitamin D
The nurse assesses a child with intussusception. Which assessment findings require priority intervention? 1. Abdominal rigidity with guarding 2. Absence of tears in crying child with IV start 3. Blood-streaked mucous stool in diaper 4. Sausage shaped right sided mass on palpation
1. Abdominal rigidity with guarding **Intussusception occurs when part of the intestine telescopes into another part and causes a blockage. Tissue death as well as perforation of the bowel can happen. If perforation happens then the child can develop peritonitis where the peritoneum in the abdomen becomes inflamed due to the infection. This can quickly lead to sepsis and multiple organ failure. Peritonitis is characterized by fever, abdominal rigidity, guarding and rebound tenderness. It is a surgical emergency
A mother reports to the pediatric nurse that her 3 year old child coughs at night and at times until he vomits. The symptoms have not improved over the past 2 months despite multiple OTC cough medications. What should the nurse explore related to a possible etiology? 1. Ask about exposure to triggers such as pet dander 2. Assess for the presence of a butterfly rash 3. History of intolerance to wheat food products 4. Palpate for an abdominal mass from pyloric stenosis
1. Ask about exposure to triggers such as pet dander **Pediatric asthma can present as night coughing until the child vomits. Frequent cough especially at night is a warning sign that the child's airway is sensitive to stimuli. "Silent asthma" affected by tobacco smoke, pet dander, air pollution, food allergies.
The school nurse assesses an 8 year old with a history of asthma. The nurse notes mild wheezing and coughing. Which action should the nurse perform first? 1. Assess the client's peak expiratory flow 2. Call the healthcare provider 3. Educate the client about avoiding triggers 4. Notify the client's parents
1. Assess the client's peak expiratory flow **By assessing the peak expiratory flow, the nurse can determine the severity of the asthma symptoms
The parent of a 21 day old male infant reports that the infant is "throwing up a lot" Which assessments should the nurse make to help determine if pyloric stenosis is an issue? SATA 1. Assess the parent's feeding technique 2. Check for family history of gluten enteropathy 3. Check for history of physiological hyperbilirubinemia 4. Check if the vomiting is projectile 5. Compare current weight to birth weight
1. Assess the parent's feeding technique 4. Check if the vomiting is projectile 5. Compare current weight to birth weight
The nurse plans care for a pediatric client who has just undergone a cleft palate repair. Which of the following interventions should the nurse include in the plan of care? SATA 1. Assist and encourage caregivers to hold and comfort the child 2. Offer a pacifier in between feedings to promote the child's comfort 3. Position the child supine with an elevated head of bed after feedings 4. Remove elbow restraints per policy for skin and circulatory assessment 5. Use tongue blade and penlight to assess surgical site every 4 hours
1. Assist and encourage caregivers to hold and comfort the child 3. Position the child supine with an elevated head of bed after feedings 4. Remove elbow restraints per policy for skin and circulatory assessment
The school nurse is teaching a class of 10 year old children about prevention of dental caries. Which recommendations would be part of the nurse's teaching plan? SATA 1. Chew sugar free gum 2. Drink fruit drinks/juices instead of sugary carbonated beverages 3. Include milk, yogurt and cheese in dietary intake 4. Minimize consumption of sweet, sticky foods 5. Rinse mouth with water after meals when brushing is not possible
1. Chew sugar free gum 3. Include milk, yogurt and cheese in dietary intake 4. Minimize consumption of sweet, sticky foods 5. Rinse mouth with water after meals when brushing is not possible
A newborn is being evaluated for possible esophageal atresia and tracheoesophageal fistula. Which finding is the nurse most likely to observe? 1. Choking and cyanosis during feeding 2. Concave abdomen 3. Diminished lung sounds 4. Projectile
1. Choking and cyanosis during feeding **Esophageal atresia and tracheoesophageal fistula consists of a variety of congenital malformations that occur when the esophagus and trachea DO NOT properly separate or develop. **Aspiration is the greatest risk for clients with EA/TEF and the newborns demonstrates signs of the condition require immediately placed on nothing by mouth status
A home health nurse is managing care for an adolescent client with cystic fibrosis. Which of the following potential complications should the nurse consider when developing a nursing care plan? SATA 1. Chronic hypoxemia 2. Diabetes insipidus 3. Frequent respiratory infections 4. Obesity 5. Vitamin deficiencies
1. Chronic hypoxemia 3. Frequent respiratory infections 3. Frequent respiratory infections **Cystic Fibrosis is an inherited disorder characterized by thickened secretions due to impaired chloride and sodium channel regulation that causes exocrine gland dysfunction.
Which pediatric respiratory presentation in the emergency department is a priority for nursing care? 1. Client with an acute asthma exacerbation but no wheezing 2. Client with bronchiolitis with low grade fever and wheezing 3. Client with runny nose with seal like barking cough 4. Cystic fibrosis client with fever and yellow sputum
1. Client with an acute asthma exacerbation but no wheezing **An acute asthma exacerbation happens when a child has rapid, labored respirations using accessory muscles. Wheezing sounds are not heard due to lack of airflow. This "silent chest" is an ominous sign and an emergency priority.
The home health nurse is visiting an infant who recently had surgery to repair tetralogy of Fallot. Which of the following signs of heart failure should the nurse teach the parents to report to the healthcare provider? SATA 1. Cool extremities 2. Intense in appetite 3. Puffiness around the eyes 4. Reduction in number of wet diapers 5. Weight gain
1. Cool extremities 3. Puffiness around the eyes 4. Reduction in number of wet diapers 5. Weight gain
A nurse is teaching the parents of an infant with tetralogy of fallot. Which of the following actions should the nurse include to reduce the incidence of hypercyanotic spells? SATA 1. Encourage smaller, frequent feedings 2. Offer a pacifier when the infant begins to cry 3. Promote a quiet period upon waking in the morning 4. Swaddle the infant during procedures 5. Turn the infant frequently during sleep
1. Encourage smaller, frequent feedings 2. Offer a pacifier when the infant begins to cry 3. Promote a quiet period upon waking in the morning 4. Swaddle the infant during procedures **During an acute "tet" spell the infant is placed in a knee to chest position to improve pulmonary blood flow
The nurse is providing discharge instructions to the parent of a child with Kawasaki disease. The nurse informs the parent that the presence of which symptom should be immediately reported to the health care provider? 1. Fever 2. Irritability 3. Knee pain 4. Skin peeling
1. Fever **Kawasaki disease is a systemic vasculitis of childhood that presents with more than 5 days of fever, conjunctivitis, lymphadenopathy, mucositis, hand/foot swelling and a rash
The nurse is caring for a 2 year old who is receiving a saline enema for treatment of intussusception. Reporting which client finding to the healthcare provider is most important? 1. Passed a normal brown stool 2. Passed a stool mixed with blood 3. Stopped crying 4. Vomited a third time
1. Passed a normal brown stool The passage of normal brown stools indicates a reduction of intussusception, so HCP should be notified immediately to modify plan of care and stop plans for surgery.
The nurse is teaching a 9 year old child with asthma how to use a metered dose inhaler. Place the instructions in the appropriate order. 6. Rinse mouth with water 3. Place lips tightly around the mouth piece 1. Shake MDI and attach it to spacer 5. Take a slow deep breath and hold for 10 seconds 2. Exhale completely 4. Deliver one puff of medication into spacer
1. Shake MDI and attach it to spacer 2. Exhale completely 3. Place lips tightly around the mouth piece 4. Deliver one puff of medication into spacer 5. Take a slow deep breath and hold for 10 seconds 6. Rinse mouth with water
A nurse receives report on a group of clients. Which client should the nurse assess first? 1. A preschool age child with a harsh cough, expiratory wheezes, and mild intercostal retractions 2. A toddler playing with small toys who appears in distress, has circumoral cyanosis and cannot speak 3. A toddler with a barking cough, infrequent inspiratory stridor and oxygen saturation of 94% on room air 4. An infant with an axillary temperature of 100.1 who is tugging at the left ear
2. A toddler playing with small toys who appears in distress, has circumoral cyanosis and cannot speak
The clinic nurse supervises a graduate nurse who is teaching the parents of a 2 year old with acute diarrhea about home management. The nurse would need to intervene when the graduate nurse provides which instruction? 1. Do not administer antidiarrheal medications to your child 2. Follow the bananas, rice, applesauce and toast diet for the next few days 3. Record the number of wet diapers and return to the clinic if you notice a decrease 4. Use a skin barrier cream such as zinc oxide in the diaper area until diarrhea subsides
2. Follow the bananas, rice, applesauce and toast diet for the next few days **When a child is experiencing acute diarrhea, the priority to monitor for is dehydration. The treatment is oral rehydration solutions and an early re-introduction of the child's normal diet.
A parent brings a 6 month old child to the primary health provider after the child abruptly started crying and grabbing intermittently at the abdomen. The client's stool has a red, currant jelly appearance. What intervention does the nurse anticipate? 1. Administer epoetin alfa (erythropoietin) 2. Give air (pneumatic) enema 3. Have the parent give 2 ounces of extra juice a day for constipation 4. Perform hemoccult test on stool
2. Give air (pneumatic) enema **Intussusception is a process which one part of the intestinal obstruction during infancy. **The child will fell periodic pain in association with the legs drawn up toward the abdomen. Ongoing obstruction can compromise circulation, causing mucosal ischemia, occult bleeding and if left untreated still a grossly bloody "currant jelly" stool (which is a mixture of blood and mucus)
The school nurse creates a cafeteria menu for a newly enrolled child with celiac disease. Which lunches would be appropriate for this child? SATA 1. Beef barley soup with mixed vegetables and french bread 2. Grilled chicken, baked potato and strawberry yogurt 3. Mexican corn tacos with ground beef and cheese 4. Peanut butter and jelly on rice cakes with an oatmeal cookie 5. Rice noodles with chicken and broccoli
2. Grilled chicken, baked potato and strawberry yogurt 3. Mexican corn tacos with ground beef and cheese 5. Rice noodles with chicken and broccoli
The nurse teaching the parents of a child diagnosed with cystic fibrosis will advise the parents to choose foods that satisfy which recommended diet? 1. Gluten free with added protein 2. High calorie, high protein, high fat 3. High protein, low fat, low phosphate 4. High protein, low fat, low sodium
2. High calorie, high protein, high fat **Cystic fibrosis is a protein responsible for transporting sodium and chloride is defective and causes the secretions from the exocrine glands to be thicker and stickier than normal. **To meet with the growth needs of CF, a diet high in calories, fat, and protein are required.
The RN is teaching a parent of a 6 year old about behavioral strategies for treating fecal incontinence due to functional constipation. Which statement by the parent indicates a need for further teaching? 1. I will give my child a picture book to look at during toilet time 2. I will give my child a reward for each bowel movement while sitting on the toilet 3. I will keep a log of my child's bowel movements, laxative use and episodes of soiling 4. I will schedule regular toilet sitting time for my child
2. I will give my child a reward for each bowel movement while sitting on the toilet **Fecal incontinence refers to the repeated passage of stool in inappropriate placed by children.
The nurse has provided teaching about home care to the parent of a 10 year old with cystic fibrosis. Which of the following statements by the parent indicates that teaching has been effective? SATA 1. Chest physiotherapy is administered only if respiratory symptoms worsen 2. I will give my child pancreatic enzymes with all meals and snacks 3. I will increase my child's salt intake during hot weather 4. Our child will need a high carb, high protein diet 5. We will limits our child's participation in sports activities
2. I will give my child pancreatic enzymes with all meals and snacks 3. I will increase my child's salt intake during hot weather 4. Our child will need a high carb, high protein diet
The nurse has received report on 4 pediatric clients on a telemetry unit. Which client should the nurse assess first? 1. Adolescent client with coarctation of the aorta and diminished femoral pulses 2. Infant client with ventricular septal defect with reporting grunting during feeding 3. Newborn client with patent ductus arteriosus and a loud machinery like systolic murmur 4. Preschool client with tetralogy of fallot who has finger clubbing and irritability
2. Infant client with ventricular septal defect with reporting grunting during feeding **Ventricular septal defect is a cardiac abnormality with a septal opening between ventricles, that may progress to congestive heart failure.
The nurse is reinforcing education with the parents of a 2 year old child about diet choices to promote growth. The family observes a strict vegan diet. Which of the following statements by the nurse are appropriate? SATA 1. Diets consisting of legumes as the only protein source are sufficient for growth 2. It is important to feed your child fortified breads and cereals to help with iron intake 3. Preparing meals with vegetables and fruits will ensure sufficient vitamin B12 intake 4. Try to pair foods high in iron with foods high in vitamin C to aid iron absorption 5. Your child may require calcium and vitamin D supplementation due to lack of dairy intake
2. It is important to feed your child fortified breads and cereals to help with iron intake 4. Try to pair foods high in iron with foods high in vitamin C to aid iron absorption 5. Your child may require calcium and vitamin D supplementation due to lack of dairy intake
A nurse is assessing a 1 month old infant with an atrial septal defect. Which assessment finding does the nurse expect? 1. Muffled heart tones 2. Murmur 3. Cyanosis 4. Weak femoral pulses
2. Murmur **Atrial septal defect is an abnormal opening between the right and left atria, allowing blood from the higher pressure left atrium to flow into the lower pressure right atrium.
The nurse is assessing an infant with intussusception. Which of the following clinical findings should the nurse expect? SATA 1. Palpable olive-shaped mass in epigastrium 2. Palpable sausage-shaped abdominal mass 3. Projectile vomiting without visualized blood 4. Screaming and drawing of the knees up to the chest 5. Stool mixed with blood and mucus
2. Palpable sausage-shaped abdominal mass 4. Screaming and drawing of the knees up to the chest 5. Stool mixed with blood and mucus
A 6 month old client has been diagnosed with cystic fibrosis. Which of the following would be appropriate for the registered nurse to teach to the parents? 1. Monitor for and report development of a "white pupil" 2. Perform manual chest physiotherapy 3. Place child in knee-chest position during hypercyanotic episode 4. Provide a low calorie diet to prevent obesity
2. Perform manual chest physiotherapy **Cystic fibrosis includes treatment of chest physiotherapy performed before meals
An 8 month old infant is scheduled for a femorally inserted balloon angioplasty of a congenital pulmonic stenosis in the cardiac catheterization laboratory. Which finding should the nurse report to the healthcare provider that could possibly delay the procedure? 1. Auscultation of a loud heart murmur 2. Infant has been NPO for 4 hours 3. Infant has severe diaper rash 4. Slight cyanosis of the nail beds
3. Infant has severe diaper rash **The presence of severe diaper rash should be reported to HCP. This could delay procedure if rash is in the groin area where the access is planned for a femorally inserted arterial cannula.
The emergency nurse is admitting a 12 year old client who reports palpitations. Which action should the nurse anticipate? 1. Administering epinephrine by rapid IV push 2. Assisting the client to a tripod position 3. Instructing the client to hold their breath and bear down 4. Sedating the client for immediate asynchronous defibrillation
3. Instructing the client to hold their breath and bear down **Supraventricular tachycardia is a rapid heart rate 200-300. It can lead to life-threatening congestive heart failure if left untreated. Symptoms in children are palpations, dizziness, chest pain. Once the ECG confirms SVT the nurse should implement non-pharmacological interventions (vagal maneuvers) to convert the SVT to sinus rhythm if client is stable.
The nurse is assessing a 3 year old client in the emergency department and finds dyspnea, high fever, irritability, and open-mouthed drooling with leaning forward. The parents report that the symptoms started rather abruptly. The client has not received age appropriate vaccinations. Which set of actions should the nurse anticipate? 1. 20 gauge needle insertion at the mid axillary line for pleural aspiration 2. 4 L oxygen at 100% per nasal cannula with bilevel positive airway pressure (BPAP) ventilation standing by 3. Intubation in the operating room with a prepared tracheotomy kit standing by 4. Nebulized racemic epinephrine with pediatric anesthesiologist standing by
3. Intubation in the operating room with a prepared tracheotomy kit standing by
The mother of a 6 year old child with cystic fibrosis that has received instruction on the use of pancreatic enzymes. Which statement made by the mother indicates a need for further teaching? 1. I need to monitor the total amount of this medication that I give to my child every day 2. I should give this medication with or just before my child has a meal or snack 3. It is okay for my child to chew this medication 4. It is okay to open the capsule and sprinkle the medicine on a tablespoon of applesauce
3. It is okay for my child to chew this medication **Pancreatic enzymes are used to aid in the absorption of carbs, fat and proteins in a child with CF. They are taken with or just before every meal.
The nurse is discussing feeding and eating practices with the mother of a 1 year old. Which statement made by the mother indicates need for further instruction? 1. I give my child chopped fruit rather than juice 2. I make sure my child drinks plenty of water between meals 3. My child is fussy at bedtime so I put him to sleep with a bottle of milk 4. When I give my child a new food, I wait a week before trying a second new food
3. My child is fussy at bedtime so I put him to sleep with a bottle of milk **Putting a child to bed without a bottle of milk or other beverage containing sugar leads to extensive and rapid dental caries in the developing teeth. Known as baby bottle tooth decay.
The nurse is caring for a 4 year old who was hospitalized with influenza. Which nursing action would be most effective to maintain psychosocial integrity? 1. Encourage use of puzzles for play 2. Offering the child stacking blocks for diversion 3. Providing crayons to draw noses on face mask 4. Suggesting that playmates visit the child
3. Providing crayons to draw noses on face mask
A 2 year old in the emergency department is suspected of having intussusception. Which assessment finding should the nurse expect? 1. Black, sticky stools 2. Greasy, foul-smelling stools 3. Stools mixed with blood and mucus 4. Thin, ribbon like stools
3. Stools mixed with blood and mucus
