NURS328 ATI pt.3
A nurse is preparing to administer digoxin (Lanoxin) to a 6 month old client. Prior to administering the dose, the nurse counts the apical heart rate. The nurse should withhold the dose if the client's apical heart rate is less than what rate?
70/min rationale: Bradycardia is an adverse effect of dig. Normal: Adult = 60/min & Child = 80/min & Infant = 100/min
A nurse in a family health clinic is performing a routine physical examination of a client who is about to enter high school. The nurse observes an abnormal lateral curvature of the spine. The nurse should expect the provider to document which of the following disorders? a. Scoliosis b. Kyphosis c. Lordosis d. Ankylosis
A
A nurse is admitting a 9 year old child who has acute rheumatic fever. When obtaining the client's history, it is appropriate for the nurse to ask the parent which of the following questions? a. "Has your son had a sore throat recently?" b. "Was your son born with this cardiac defect?" c. "Has your child had any injuries recently?" d. "Are you aware that your son will have to be in isolation?"
A
A nurse is caring for a child that has red marks across his cheeks. Which of the following is an appropriate action for the nurse to take? a. Assess the rest of the child's body for a rash b. Refer the family to child protective services c. Question the parents about how the marks occurred on the child's cheeks d. Obtain the child's temperature
A
A nurse is caring for a child with Kawasaki disease. Which of the following is the primary system involved with this diagnosis? a. Cardiovascular b. Gastrointestinal c. Integumentary d. Respiratory
A
A nurse is caring for a child with Legg-Calve-Perthes disease that is in Buck extension traction. Which of the following is an appropriate action for the nurse to take? a. Reposition the child every 2hrs b. Remove traction boot during bath c. Apply antibiotic ointment to pin sites daily d. Reduce fluid intake
A
A nurse is caring for an 8 year old admitted to the hospital with a diagnosis of acute rheumatic fever. Which of the following nursing assessments is most important immediately after admission? a. Auscultation of the rate and characteristics of heart sounds b. Use of a pain-rating tool to determine the severity of joint pain c. Identifying the degree of parental anxiety related to the diagnosis d. Assessing the client's erythematous rash
A
A nurse is preparing to begin chest compressions for an infant. The nurse should perform compressions using which of the following techniques? a. Deliver compressions at 1/3 to 1/2 the depth of the chest b. Deliver compressions with the heel of one hand only c. Deliver compressions just above the nipple line d. Deliver compressions at a depth of 1 1/2 to 2 inches
A
A nurse is teaching a parent of a child who has eczema. Which of the following should be included in the teaching? a. Apply a cool, wet compress to the affected area b. Launder clothing with fabric softener c. Give bubble baths every day d. Dress in thermal clothing during the night
A
A parent tells the nurse in the pediatric clinic that her toddler drinks a quart of milk a day and has a poor appetite for solid foods. The nurse should explain that this client is at risk for which of the following disorders? a. Iron-deficiency anemia b. Rickets c. Diabetes mellitus d. Obesity
A
A school nurse identification that a child has pediculosis capitis and educates the child's parent about the condition. Which of the following statements by the parent indicates an understanding of the teaching? a. "All recently worn clothing, bedding, and towels must be washed in hot water" b. "My child must have a physician's note to return to school" c. "I will treat all the family members to be on the safe side" d. "Toys that can't be dry cleaned or washed must be thrown out"
A
A nurse is collecting data on a child who is descending stairs by placing both feet on each step while holding on to the railing. This is developmentally appropriate at which of the following ages? a. 3 years b. 4 years c. 5 years d. 6 years
A rationale: @ 3y/o, children can typically go up stairs alternating feet but still descend by placing both feet on each step; @ 4 y/o, they descend using alternating feet and holding the railing; @ 5y/o, children's balance improves; @6y/o, child is proficient at going up and down the stairs
A child who has leukemia is being admitted. Several rooms are available on the pediatric floor. Which of the following clients should the nurse place in the same room with this child? a. A child who has nephrotic syndrome b. A child recovering from a ruptured appendix c. A child who has rheumatic fever d. A child who has cystic fibrosis
A rationale: A child who has leukemia is at risk for infection. Nephrotic syndrome is not an infectious disorder, and therefore, poses no risk to the child with leukemia
A nurse is assessing a child for pediatrician capitis. Which of the following manifestations should the nurse recognize as an indication of this condition? a. Firmly attached white particles on the hair b. Itching and scratching of the head c. Patchy areas of hair loss d. Thick, yellow, rusted lesion on a red base
A rationale: A) Head lice are tiny insects that appear like flakes of dandruff; B) There are many causes of scalp itching; C) A typical finding of ringworm, a superficial fungal infection of scalp; D) This is common in impetigo, a superficial skin infection that may often involve the face or scalp
A nurse is caring for a 4 year old child who has been newly diagnosed with diabetes mellitus and is distressed after an insulin injection. Which of the following play activities should the nurse recognize as therapeutic in helping the child deal with the injection? a. A needless syringe and a doll b. A video game c. A story book about a child with diabetes d. A period of play in the playroom
A rationale: It will allow the child to act out of feelings of anger and helplessness
A nurse in a provider's office is caring for a school-age child whose mother reports dandruff and a rash on the back of her child's neck. On examination, the nurse notices the white flakes don't brush off the hair. The nurse suspects which of the following disorders? a. Pediculosis capitis b. Psoriasis c. Seborrheic dermatitis d. Tinea capitis
A rationale: It's headlice. A papular rash may be present at the nape secondary to scratching
A nurse is providing teaching about self-administration of insulin to the parent of a school-age child newly diagnosed with diabetes mellitus. Which of the following statements by the parent indicates a need for further teaching? a. "I will be sure my child aspirates before injecting the insulin" b. "The insulin can be injected anywhere there is adipose tissue" c. "I will be sure my child rotates sites after 5 injections in one area" d. "The insulin should be injected at a 90 degree angle"
A rationale: It's not necessary to aspirate before injecting insulin
A nurse is providing teaching about iron deficiency anemia to the parents of a toddler. Which of the following should the nurse recommend as a method of preventing iron deficiency anemia? a. Avoid a diet consisting of primarily milk b. Administer fat-soluble vitamins daily c. Include fluoridated water in the diet d. Limit intake of high-protein foods
A rationale: Milk has a poor source of iron and if kid drinks >1L/day, it's bad
A child is admitted with a possible diagnosis of Wilm's tumor (nephroblastoma). The nurse should obtain a sign with which of the following warnings to be placed over the child's bed? a. Do not palpate abdomen b. No venipuncture or blood pressure in left arm c. Contact precautions d. Collect all urine
A rationale: Wilm's tumor is a neoplasm of the kidney (nephroblastoma). This tumor is encapsulated, and palpation may cause it to rupture, which would allow seeding of the tumor into the pelvic cavity. The nurse should place a sign above the client's bed warning all caregivers not to palpate the abdomen so that the tumor remains intact until removed in surgery
A nurse is completing a history and physical on a 3 year old child who is admitted for a surgical repair of Tetralogy of Fallot (TOF). Which of the following manifestations of the condition should the nurse expect? (Select all that apply) a. Polycythemia b. Hypertension c. Clubbing of the nail beds d. Failure to thrive e. Pallor f. Murmur
ACDF rationale: Polycythemia is correct since it results as a compensatory measure when the child's body produces extra blood cells in an attempt to increase the oxygen carrying capacity of the blood. HTN is incorrect. Clubbing of the nails is correct since it results from chronic hypoxia of the distal extremities. Failure to thrive is correct since difficulty feeding and failure to thrive may result from the child expending more energy to eat than it's able to take in. Murmur is correct (a loud, long systolic murmur)
A nurse is caring for a 17 year old client who is experiencing a relapse of leukemia and is refusing treatment. The client's mother insists that the client receive treatment. Which of the following nursing actions is appropriate at this time? a. Start the IV per the parent's request b. Notify the charge nurse of the situation c. Administer a sedative to calm the client d. Offer the client an antiemetic
B
A nurse is caring for a child admitted with suspicion of rheumatic fever. An anti-streptolysin O (ASO) titer is drawn on the child. The parent asks the nurse why the tier was drawn. The nurse should inform the child's parent that the titer will tell if the child a. Has rheumatic fever b. Had a recent streptococcal infection c. Has a therapeutic blood level of an aminoglycoside d. Has immunity to streptococcal bacteria
B
A nurse is caring for a child diagnosed with tinea pedis. The nurse should respond with which of the following when asked by the parent what the common name for this disorder is? a. Shingles b. Athlete's foot c. Fever blister d. Valley fever
B
A nurse is caring for a child who has rheumatic fever. When obtaining the client's medical history from the parent, the nurse recognizes the significance of which of the following data as the possible source of the child's infection? a. A classmate has fifth disease b. A sibling had a sore throat 3 weeks ago c. The father had gastritis 2 weeks ago d. A neighbor's child had chickenpox
B
A nurse is instructing a mother on how to care for a child who has impetigo contagiosa. Which of the following should the nurse plan to include in her education of the mother? a. Isolate this child from others in his family b. Wash toys with soap and very hot water c. Vaccinated the other family member for disease d. Implement no special precautions
B
A nurse is monitoring a child for acute signs of lead poisoning. Which of the following should the nurse expect the client to manifest? a. Increase urinary output b. Anorexia c. Diarrhea d. Jaundice
B
A nurse is planning care for an infant. Which of the following would be the most appropriate site to assess a pulse? a. Carotid artery b. Apex of the heart c. Brachial artery d. Temporal artery
B
A nurse is providing teaching about lice to the parent of a school-aged child at a well child visit. Which of the following should be included in the teaching? a. "Lice can jump from one child to another" b. "Encourage your child to avoid sharing hats with other children" c. "Lice do not survive away from the host" d. "Washing your child's hair daily will prevent lice"
B
A nurse is providing teaching to an adolescent diagnosed with type 1 diabetes mellitus. Which of the following should the nurse include in the teaching? a. Administer glucagon (GlucaGen) for hyperglycemia b. Obtain an influenza vaccine annually c. Inject insulin in the deltoid muscle d. Take glyburide (DiaBeta) with breakfast
B rationale: Glucagon is administered for hypoglycemia; Insulin should be injected subcutaneously not intramuscularly (45 degree); Glyburide is contraindicated for clients with type 1 diabetes and shouldn't be taken
A nurse is caring for an infant who has congestive heart failure (CHF) secondary to a ventricular septal defect (VSD) and was brought to the clinic by the parent with a report of poor feeding. After instructing the parent about nasogastric (NG) tube feedings, the nurse evaluates that teaching has been effective when the parent states, "I will a. Give every other feeding by the NG tube" b. Nurse my baby for 20min then give the rest by NG tube" c. Administer all of my baby's feedings through the NG tube" d. Let my baby suck until tired"
B rationale: Nursing the infant for 20min allows the baby gratification from sucking, and the limited time frame does not place great exertion on the heart nor does it cause excessive fatigue. Using the NG tube to administer the additional feeding ensures adequate calorie and fluid intake
A nurse is caring for a pediatric client who is about to receive chemotherapy to treat leukemia. The nurse reviewing the client's laboratory results notes that her platelet count is low. Which of the following precautions should the nurse add to the client's care plan? a. Neutropenic b. Bleeding precautions c. Contact d. Droplet
B rationale: With a low platelet count, clients are at risk for bleeding. Bleeding precautions involves specific measures for decreasing bleeding risk, such as soft bristle toothbrushes, avoiding IM injections, and preventing constipation
A nurse is caring for an infant who has a congenital heart defect. Which of the following is associated with increased pulmonary blood flow? a. Coarctation of the aorta b. Patent ductus arteriosus c. Tetralogy of Fallot d. Tricuspid atresia
B rationale: the area between the pulmonary artery and aorta remains open, allowing the blood to flow through the PDA and back to the pulmonary artery and lungs
A nurse is teaching a parent of a child who has a fracture of the epiphyseal plate. Which of the following is an appropriate statement by the nurse? a. "The blood supply to the bone is disrupted" b. "Normal bone growth can be affected" c. "Bone marrow can be lost through the fracture" d. "The healing process will take longer"
B rationale: this must be detected and treated rapidly
A nurse at a pediatrician's office is contacted by a parent whose child just ingested half a bottle of vitamins with added ferrous sulfate. Which of the following instructions should the nurse provide to the parent? a. Provide a high carbohydrate meal b. Give the child syrup of ipecac c. Contact the poison control center d. Do nothing because the ferrous sulfate will induce vomiting
C
A nurse at the pediatric hotline receives a call from a mother who plans to administer aspirin (St. Joseph Children's) to a toddler for a fever and wants to know the dosage. Which of the following statements by the nurse is an appropriate response? a. "You'll have to call your physician" b. "Give her no more than three baby aspirin every four hours" c. "Give her acetaminophen not aspirin" d. "Follow directions on the aspiration bottle for her age and weight"
C
A nurse in a pediatric clinic is caring for a child with iron deficiency anemia who has a new prescription for ferrous sulfate (Fer-In-Sol) tablets. Which of the following instructions should be given to the parent regarding administration of this medication? a. Give with an 8oz glass of milk b. Administer at meal time c. Give with orange juice d. Administer at bedtime
C
A nurse is planning care for a child who has sickle cell crisis. Which of the following actions is included in the plan of care? a. Active ROM exercises daily b. Application of cold compresses to the affected area c. Promote hydration with IV and oral fluids d. Implement pain management on a PRN basis
C
A school nurse is completing routine health evaluation for school-aged children. Which of the following should alert the nurse to the possibility of pediculosis? a. Patches of baldness b. Blisters on the scalp c. Reports of scalp itchiness d. Dry patches on the scalp
C
A pediatric client in sickle cell crisis comes to the hospital with his mother. When assessing the client, the nurse should expect to find which of the following manifestations? a. Fever b. Bradycardia c. Pain d. Constipation
C rationale: A client who is in sickle cell crisis generally has severe pain resulting from tissue hypoxia and necrosis
A nurse at the pediatric hotline receives a call from a mother who plans to administer aspirin (St. Joseph Children's) to a toddler for a fever and wants to know the dosage. Which of the following statements by the nurse is an appropriate response? a. "You'll have to call your physician" b. "Give her no more than three baby aspirin every four hours" c. "Give her acetaminophen, not aspirin" d. "Follow directions on the aspirin bottle for her age and weight"
C rationale: Giving children aspirin can cause Reye Syndrome
A school nurse conducting a screening for pediculosis identifies several children who require treatment. Which of the following is an appropriate instruction for the nurse to give the children's parents? a. Soak all combs and hairbrushes in alcohol b. Inspect any dogs or cats at home for lice c. Seal non-washable items in airtight plastic bags d. Spray countertops and sinks with insecticide
C rationale: Seal any items they cannot wash, vacuum, or dry clean in airtight bags for 14 days to kill any lice on them
A nurse is discharging a child with sickle cell anemia after an acute crisis episode. Which of the following should the nurse teach the child's parents to do? a. Monitor the child's temperature daily b. Restrict outdoor play activity to 1hr per day c. Encourage the child to drink lots of fluids d. Have the child eat a high-protein diet
C rationale: The nurse should give the parents a specific amount of fluid to make sure the child drinks each day
A nurse is caring for a 7 year old client who has a diagnosis of upper respiratory infection and a history of type 1 diabetes mellitus. Which of the following statements by the mother indicates a need for further instructions? a. "I will encourage drinking a half a cup of water or sugar-free fluids every 30min" b. "I will report a change in breathing or any signs of confusion" c. "I will notify the doctor if the temperature is not controlled with acetaminophen" d. "I will continue to check his blood sugar two times a day"
D
A nurse is caring for an infant with diaper dermatitis. Which of the following is an appropriate action by the nurse? a. Apply a light layer of talc with each diaper change b. Change to cloth diapers until the skin is healed c. Exposed excoriated area to hot air frequently d. Use a moisturizer to wipe urine from the skin
D
A nurse is preparing a presentation for a local community center. What information should the nurse include regarding lead poisoning in children? a. Lead poisoning occurs frequently in children of low socioeconomic status b. Lead poisoning rarely occurs during the toddler stage c. Lead poisoning occurs more often in house built before 1985 d. Lead poisoning is common in children who have a history of pica
D
A nurse is teaching a parent of a child with hemophilia how to control a minor bleeding episode. Which of the following statements by the parent indicates a need for further teaching? a. "I will have my child rest" b. "I will elevate the affect part" c. "I will compress the site" d. "I will apply heat"
D
A parent calls the pediatric clinic to report that her child has a bloody nose. The nurse should give the parent which of the following instructions to stop the bleeding? a. Place the child in a sitting position with her head tilted back b. Apply ice at the base of the nose for 5 min and then check for bleeding c. Place the child in a supine position with a pillow under her back d. Have the child sit with her head tilted forward and hold pressure on her nose for 10min
D
A nurse is planning care for a child who has juvenile rheumatoid arthritis. Which of the following is an appropriate action for the nurse to take? a. Administer opioids on a schedule b. Schedule prolonged periods of complete joint immobilization daily c. Apply cool compresses for 20min every hr d. Maintain right splints to the affect joint
D rationale: Maintaining right splints to the affected joints will assist in ROM. Therefore, is an appropriate action for the nurse to take
A nurse is completing discharge teaching to the parent of a child with a new diagnosis of diabetes mellitus. Which of the following statements by the parent requires clarification of the teaching? a. "The onset of low blood glucose usually occurs rapidly" b. "My son may complain of feeling shaky when he has low blood glucose level" c. "Sweating can occur with hypoglycemia" d. "My son may have nausea and vomiting with hypoglycemia"
D rationale: N/V happens in hyperglycemia
A nurse is caring for a toddler who has a fractured right femur and is in Bryant's traction. When monitoring to determine if the traction is appropriately assembled, the nurse expects to observe which of the following? a. Skin straps maintaining the leg in an extended position b. Weights attached to a pin that is inserted in the femur c. A padded sling under the knee of the affected leg d. The buttocks elevated slightly off the bed
D rationale: The child's hips are flexed at a 90° angle with the legs suspended by pulleys and weights. The weights must hang freely from the bed to maintain alignment
A nurse is reinforcing teaching with the parents of a child who is taking iron supplements. a. "The medication should be administered in one large dose per day" b. "Restricting fiber from our child's diet will help absorption of the iron" c. "The medication will be more effective if it is administered with meals" d. "Our child's blood count will need to be monitored routinely for several weeks"
D rationale: The child's response to treatment will be determined by monitoring the hgb and hct during routine blood tests. Treatment can take up to 3mo to be effective. Oral iron supplements are best administered on an empty stomach and 2hr after milk or antacids. They may cause gastrointestinal disturbances, such as diarrhea or constipation, which will get better over time. If liquid form is admin, the parents should mix it with a small amount of water or juice and have the child sip through a straw if able or with a dropper toward the back of the mouth to avoid staining the teeth
A nurse is caring for a 10 month old infant who is in a cast for developmental dysplasia of the hip (DDH). Which of the following strategies should the nurse implement to promote the infant's growth and development? a. The colorful latex balloons to the side of the crib b. Provide a small electronic toy c. Change the infant's diaper as soon as soiling occurs d. Allow infant to stand in the crib
D rationale: The infant should not be restricted from normal activities. The infant can be held and allowed to walk in a cast or orthotic device. Allowing the child to participate in normal developmental activities will promote growth and development
A nurse is reinforcing teaching to a 17 year old female client who has severe acne regarding the use of isotretinoin (Accutane). Which of the following side effects should the nurse instruct the client is the priority to report to the provider? a. Frequent nosebleeds b. Itching of skin c. Back pain d. Feelings of isolation
D rationale: This may indicate suicide ideation, which could lead to self harm
A home health nurse is developing a plan of care for a child who has cerebral palsy. The nurse determines that the priority goal for this client will involve a. Providing respite services for the parents b. Improving communication skills c. Fostering self-care activities d. Modifying the environment
D rationale: Using the safety and risk reduction priority-setting framework, maintaining safety is the highest priority for this client. Modification of the environment included making child's home accessible and safe from hazards that would cause injury
