Pediatrics Ch. 28-31
The nurse is teaching a group of novice nurses how to assess bowel sounds. Which statement will the nurse include in the education? "Bowel sounds will be audible by the naked ear unless distention is present." "Bowel sounds should be present within the first few days of life." "Auscultated all four quadrants for a full minute each." "Hypoactive bowel sounds are expected in a client with diarrhea."
"Auscultated all four quadrants for a full minute each."
The nurse is beginning a health history with a 3-year-old child. Which question would the nurse ask the mother first? "Has your child been ill in the past?" "Is your child ill in any way?" "Tell me about your child." "Do you have any concerns about your child?"
"Do you have any concerns about your child?"
A nurse is teaching a parent ways to reduce fever in a child. What statement made by the parent would require further education? "I will give my child a tepid sponge bath to reduce the fever." "I will be sure to not overdress or heavily cover my child." "I will administer acetaminophen if my child develops a fever." "I will give my child fluids so that dehydration is not a problem."
"I will give my child a tepid sponge bath to reduce the fever."
A nurse is wrapping up a health interview with the parent of a toddler. Which would be the best question or statement to end the interview? "Is there anything more about your child that we should know?" "Was yesterday a fairly typical day for your child?" "I'd like to ask about different parts of your child's body, from the head down to the toes, just to be certain I don't miss anything." "Before we talk about any past illnesses or happenings with your child, let me ask you some questions about your family as a whole."
"Is there anything more about your child that we should know?"
A 10-year-old is scheduled for an appendectomy in 6 hours. The child is placed on NPO status and wants to know why he cannot have anything to eat or drink. What is the best explanation by the nurse? "We cannot give you anything to eat or drink because you could vomit during the procedure and aspirate." "We cannot give you anything to eat or drink before your procedure because we do not want you to get an upset stomach." "Having surgery is a serious matter and we do not want you to have any complications from taking anything by mouth." "The surgeon ordered you to be NPO and we have to abide by that rule."
"We cannot give you anything to eat or drink before your procedure because we do not want you to get an upset stomach."
A venous blood specimen is needed from a young school-age child who is anxious about the process. How will the nurse work with the child to defuse the fear? Tell the child about the plans for the blood test as far ahead of the event as possible. Acknowledge that nobody likes to have blood taken. Explain the importance of the blood draw. Talk about how much everyone in the next room enjoys the brave child in the next room.
Acknowledge that nobody likes to have blood taken.
A child is prescribed several diagnostic procedures. How can the nurse advocate for this client? Advocate for procedures to be separated to allow time for food and rest. Attend all procedures with the child when going to another area of the hospital. Ensure that all procedures are performed with the child under general anesthesia. Ask that the procedures be scheduled back to back to prevent fatigue.
Advocate for procedures to be separated to allow time for food and rest.
An infant is scheduled to have a painful procedure performed. Which nursing action provides the best support for the parents and infant? Allow the parents to hold the infant during the procedure. Ask the parents to hold the child down during the procedure. Explain to the parents that infants do not experience pain. Have the parents remain outside the room while the procedure is occurring.
Allow the parents to hold the infant during the procedure.
A nurse is caring for a child on transmission-based precautions. What interventions can the nurse provide to prevent the child from feeling socially isolated? Select all that apply. Encourage family members to spend time with the child and help them with maintaining precautions. Allow the child to play with one other child on the pediatric unit. Do not allow visitors but allow the child to call family on the telephone. Arrange to spend extra time in the room when performing treatments and procedures. Make sure the child understands the isolation precautions are not a punishment.
Arrange to spend extra time in the room when performing treatments and procedures. Encourage family members to spend time with the child and help them with maintaining precautions. Make sure the child understands the isolation precautions are not a punishment.
When 12-year-old Chelsie comes in for her annual check-up, the nurse must take a health history and do a physical exam. What is the most appropriate manner for the nurse to obtain a health history? Ask Chelsie to wait outside while the nurse talks with her mother. Ask Chelsie's mom to leave the room. Ask Chelsie if she minds if her mother is in the room with her. Ask Chelsie to fill out the health form and return it herself.
Ask Chelsie if she minds if her mother is in the room with her.
The nurse wants to find out how much time a preschooler spends in various activities throughout the day. What should the nurse do to learn this information? Ask the parents to name the games the child knows. Ask the child how much time the mother is with the child. Ask the parents how many hours are spent playing with the child each day. Ask the parents to complete a day history.
Ask the parents to complete a day history.
A nasogastric tube for enteral feedings has just been inserted in a 6-month-old infant. What should the nurse do to determine if the tube is in the client's stomach? Administer 1 ml of fluid and observe for coughing. Listen at the distal end of the tube for bowel sounds. Aspirate the tube for stomach contents. Lower the end of the tube and observe for drainage.
Aspirate the tube for stomach contents.
The nurse is caring for a 6-year-old client who is prescribed to cough and deep breathe following surgery. Which nursing action is best for this client? Have the parents encourage the child to cough and deep breathe every 2 hours. Blow a pinwheel and bubbles with the child. Teach the child to use an incentive spirometer. Arrange for respiratory therapy to do coughing and deep breathing exercises with the child.
Blow a pinwheel and bubbles with the child.
A hospitalized child has a pulse oximeter attached to his finger. What interventions would the nurse implement in caring for this client? Check the skin under the probe every 2 hours for tissue perfusion. Change the probe site location every 8 hours. If left on indefinitely, check every 4 hours to ensure that the probe is secure. Check the pulse oximetry alarms at the end of the shift.
Check the skin under the probe every 2 hours for tissue perfusion.
A preschool teacher calls the hospital and wants to introduce the concept of a hospital to her preschool class in case they ever get sick and need to be admitted. What resources could the child life specialist provide for this group to aid in their learning? Select all that apply. Provide a room for the class with hospital gowns, masks and equipment used on children. Let the children lie in the beds, use the call lights and practice being a patient. Tell the children that hospitals are places for sick people to come and sometimes they don't leave. Tour the hospital, including the playrooms on the pediatric floors. Offer to let them see and play with the injection equipment such as syringes and needles.
Provide a room for the class with hospital gowns, masks and equipment used on children. Tour the hospital, including the playrooms on the pediatric floors. Let the children lie in the beds, use the call lights and practice being a patient.
The toddler needs elbow restraints to keep his hands away from a facial wound. What will the nurse do to best ensure their safe use? Choose restraints long enough to fit closely under the arm and extend over the wrist. Have the parent check for equal warmth bilaterally in his hands and fingers. Remove one restraint at a time on a regular basis to check for skin irritation. Apply lotion to the skin prior to putting on the restraints.
Remove one restraint at a time on a regular basis to check for skin irritation.
A parent has brought the child into the clinic for a routine health assessment. The parent asks when routine screening for back symmetry will begin. Which response by the nurse is most accurate? Young adulthood Infancy Adolescence School age Preschool age
School age
The pediatric nurse is caring for a group of children. Which clinical situation will the nurse identify as being a safety concern? Sleepy mother holding sleeping child at the child's bedside Infant placed in crib with all railings in the up position Child playing with a rubber ball while wearing supplemental oxygen Infant who can stand placed in a crib with a top on it
Sleepy mother holding sleeping child at the child's bedside
An adolescent is scheduled to have the present gastrostomy tube replaced with a gastrostomy button. What advantage of the button over the tube will the nurse emphasize? Aspiration for residual is unnecessary. The button will not need flushing. The button will be smaller and less visible when not in use. Replacement of the button on a regular basis is rarely needed.
The button will be smaller and less visible when not in use.
The pediatric nurse is performing a head-to-toe exam on a 2-year-old child during a well child assessment. Which method will the nurse use to accurately determine the child's heart rate? counting the apical rate palpating the femoral pulse palpating the brachial pulse calculating the apical rate
counting the apical rate
The nurse is caring for an infant recovering from surgery for a cleft palate. Which type of restraint would be appropriate for the nurse to use when caring for this infant? clove hitch elbow jacket mummy
elbow
A nurse is starting an intravenous (IV) line in the antecubital fossa of a small child. What restraint would be best for the nurse to use to maintain patency of the IV? papoose board jacket restraint elbow restraint mummy restraint
elbow restraint
A nurse is assessing a Babinski reflex in a 2-day-old newborn. Which finding by the nurse would indicate a positive finding? fanning of the infant's toes curling downward of the toes withdrawing the foot from touch dorsiflexion of the newborn's toes
fanning of the infant's toes
All infants should have their head circumference measured at health assessment visits. Where should the nurse place the tape measure to obtain this measurement? the hairline in front to the hairline in back the center of the forehead to the base of the occiput the middle of the forehead through the parietal prominences just above the eyebrows through the prominent part of the occiput
just above the eyebrows through the prominent part of the occiput
On the first postoperative day, a 4-year-old child who was hospitalized for an emergency appendectomy has begun to cry relentlessly, will not let the nurse touch him or her, and keeps asking for the parent. The pediatric nurse is aware that this client is in which stage of separation? denial grief protest despair
protest
The nurse is performing an examination of the eyes of a 7-year-old child. Which finding would indicate that the third cranial nerve is intact? eyelid blinks in response to touching the cornea with a wisp of cotton pupil constriction in response to light light of an otoscope reflecting evenly off both pupils pupil dilation in response to light
pupil constriction in response to light
Which finding would the nurse interpret as least significant when assessing a child's lungs? stridor rhonchi crackles wheezing
rhonchi
The nurse obtains a stool specimen for ova and parasites. It would be important for the nurse to: keep this refrigerated. see that it arrives at the laboratory promptly. discard it if it is not yellow to green. add alcohol to prevent odor.
see that it arrives at the laboratory promptly.
The nurse should consider which stool sample collected from a child as contaminated and not acceptable for analysis? stool retrieved from a potty formed stool obtained from a bed pan a sample scraped from a diaper stool removed from surrounding urine
stool removed from surrounding urine
A preschool child has been admitted to the hospital. Which prescription should the nurse question? IV normal saline 25 ml/hour NPO tap water enema 500 ml nasogastric tube to suction
tap water enema 500 ml
Martha has her 5-year-old child at the clinic for a checkup. When reviewing the child's history, which of the following would the nurse identify as a primary preventive measure? the last hospitalization the last medication the child took the last immunizations the child obtained the type of diet the child is on
the last immunizations the child obtained
The nurse is caring for a 10-year-old child admitted for a surgical procedure to be done the next day. The nurse takes the child to a special area in the playroom and lets the child "start" an IV on a stuffed bear. This is an example of: positive reinforcement. therapeutic play. age-related activity. play therapy.
therapeutic play.
The nurse is performing a physical examination on a sleeping newborn. Which body system should the nurse examine last? lungs heart throat abdomen
throat
Which of the following are situations that might warrant a restraint of a pediatric client? Select all that apply. to keep an active child confined to bed to teach a child how to be cooperative to ensure the child's safety to protect the child from injury during a procedure or examination
to protect the child from injury during a procedure or examination to ensure the child's safety
After teaching a group of students about therapeutic play, the instructor determines that additional teaching is needed when the students identify what as a characteristic of therapeutic play? dramatization of emotions use of a highly structured format expression of feelings focus on coping
use of a highly structured format
A child is to receive an IV. The nurse knows that the first step in initiating the procedure is to: obtain consent. verify the physician's order. gather all supplies. wash hands. identify the child.
verify the physician's order.
The nurse is assessing the abdomen of a 3-year-old. Which finding should be reported immediately? rounded abdomen active bowel sounds tympany over the abdomen visible peristaltic waves
visible peristaltic waves
The nurse is taking the health history for a toddler in the emergency department. The child's parent informs the nurse that the toddler has been vomiting for the last 3 days, has a history of asthma, and was hospitalized with pneumonia and a urinary tract infection (UTI) 6 weeks ago. What would the nurse recognize as is the client's chief concern/complaint? Asthma Vomiting Pneumonia UTI
vomiting
The nurse needs to transport her preschool client to radiology for a chest X-Ray. Which transportation device would be most appropriate? wheelchair wagon stretcher crib
wagon
The nurse is caring for a preschooler who requires postsurgical breathing exercises. Which approach will best elicit the child's cooperation? "You will need to cooperate. Otherwise, you might not feel better." "Let's see who can blow these cotton balls off the table first." "Do you want to play a breathing exercise game with me?" "You need to do the breathing or you could get pneumonia."
"Let's see who can blow these cotton balls off the table first."
A parent calls the nurse in the emergency department and reports giving a tepid bath to decrease temperature in a feverish child. The parent states the child is shivering and wants to know if this means the bath was effective. What is the best response by the nurse? "Shivering means the child is chilling, which will cause the body temperature to increase." "You should pour more hot water in the tub so the child will not shiver." "The child's fever is going to go down after the bath because of the shivering." "The child may be getting ready to have seizure activity."
"Shivering means the child is chilling, which will cause the body temperature to increase."
A nurse has just received an order to apply an ice bag to a client's groin. Which of the following intervals for placement of the ice bag does the nurse plan to use? 20 minutes 10 minutes 60 minutes 30 to 45 minutes
20 minutes
Blood pressure monitoring becomes part of the routine health assessment at what age and older? 4 years 3 years 1 year 2 years birth
3 years
A 6-month-old infant is admitted to the hospital because of a fever. When the nurse obtains a health history, what data would be obtained first? Review of systems Details about the fever Family profile History of past illnesses
Details about the fever
The nurse is caring for a preoperative pediatric client. What would it be best for the nurse to do with this client? Teach technical terminology to the caregivers so they will understand what is being said postoperatively. Determine how much the child knows and is capable of understanding. Keep the child away from any food or drinks to ensure the child is NPO. Explain how the therapeutic plan can be used in preparing the child for surgery.
Determine how much the child knows and is capable of understanding.
The nurse is preparing a postsurgical care plan for an infant girl located on a general hospital unit that only occasionally admits children. To ensure the infant's safety, what should the nurse include in the plan? Place the infant in a room with an ambulatory adolescent. Place the infant in a room close to the nurses' station. Ask the family to stay with the infant at all times. Put the infant in a carrier and bring her to the nurses' station.
Place the infant in a room close to the nurses' station.
A 6-year-old child will be hospitalized for a surgical procedure. How can the nurse best ease the stress of hospitalization for this child? Tell the parents to bring toys for the child from home. There is no way to adequately prepare a child for an impending hospitalization. Prepare the child for hospitalization by explaining what to expect and showing him or her around the hospital. Have another child talk with the child to be hospitalized.
Prepare the child for hospitalization by explaining what to expect and showing him or her around the hospital.
The nurse is preparing a hospitalized 7-year-old girl for a lumbar puncture. Which actions would help reduce her stress related to the procedure? Select all that apply. Tell her not to pay attention to any sounds she might hear. Introduce her to the health care personnel. Do not allow her to see or touch the equipment. Pretend to perform the procedure on her doll. Explain the procedure to her in medical terms. Teach her the steps of the procedure.
Pretend to perform the procedure on her doll. Teach her the steps of the procedure. Introduce her to the health care personnel.
When auscultating bowel sounds, which of the following frequencies would the nurse identify as normal? Sixty per minute Thirty to 40 per minute One to two per minute Five to 10 per minute
Five to 10 per minute
A 6-year-old has just returned to his room after a spinal tap. What could the nurse do to make this unpleasant procedure less memorable for the child? Tell him he was very brave even though he cried. Give him a little toy that he has been wanting. Tell him he should not have to do this again. Tell him that his parents are very proud of him.
Give him a little toy that he has been wanting.
A nurse is admitting a 7-year-old child to the pediatric unit of the hospital. While the nurse is showing the child and parents the room and explaining where things are, the child becomes upset and frightened. What is the best action by the nurse? Keep on showing and explaining to the parents and do not include the child. Ask the parents to leave the room while explaining procedures to the child. Go slowly with the acquaintance process. Tell the child that there is nothing to be afraid of and that nobody will hurt the child during hospitalization.
Go slowly with the acquaintance process.
When an infant is scheduled for a painful procedure, what is the most important action by the nurse? Help to soothe and comfort the baby before and after the procedure. Explain the procedure to the caregiver. Explain the procedure to the client. Nothing—the infant is too young to know what is going on.
Help to soothe and comfort the baby before and after the procedure.
The nurse is preparing to assess the abdomen of a preschool-aged child. Which technique should the nurse use first? Auscultation Inspection Percussion Palpation
Inspection
Caregivers of a hospitalized toddler are being given safety instructions upon admission to the pediatric floor. Which action by the caregiver would be most important to the toddler's safety? If side rails are down, never be more than 3 feet away from the child. Show the child how to push the nurse call button. Keep the crib side rails up at all times. Keep the crib at the highest setting so the nurse can assess the child easily.
Keep the crib side rails up at all times.
Parents asks the nurse why their premature infant is receiving a feeding through the mouth rather than the nose. What is the best explanation by the nurse? It is equally acceptable to use either insertion site. Nasogastric tubes decrease the possibility of striking the vagal nerve. Newborns are obligate nose breathers so nasogastric may obstruct their breathing. Orogastric tube insertion can cause inflammation and obstruction of the nares.
Newborns are obligate nose breathers so nasogastric may obstruct their breathing.
A 10-year-old has braces on her teeth. What is most important for the nurse to assess when inspecting the mouth? Pinpoint ulcers on the gums Loose hardware Dental caries Reddened mucous membranes
Pinpoint ulcers on the gums
The health care provider orders a urinalysis on a 15-month-old toddler. The mother states that the child is not potty-trained. What is the best way for the nurse to collect the specimen? Clean off the penis with a commercial cleaning pad and catheterize the client. Aspirate urine out of the diaper with a syringe and place it in a specimen cup. Place a urine collection bag on the child after cleaning off the perineum. Observe the child for signs he needs to urinate and quickly pull the diaper down and catch the urine when he voids.
Place a urine collection bag on the child after cleaning off the perineum.
Which intervention should the nurse use when collecting a urine specimen from an 8-month-old client? Wait until the baby voids and attempt to obtain a clean-catch specimen. Wait an hour after a feeding and then apply a collection bag. Place a diaper on the baby; when it is wet then send the diaper to the laboratory. Place a urine collector on the baby just prior to feeding.
Place a urine collector on the baby just prior to feeding.
The nurse is gathering data on a child being admitted. Which would be considered collecting subjective data? Select all that apply. The nurse takes the child's vital signs and height and weight. The nurse finds out the reason for the child's visit to the health care setting. The nurse interviews the child's caregiver. The nurse observes the general appearance of the child. The nurse asks questions about the child's history.
The nurse interviews the child's caregiver. The nurse asks questions about the child's history. The nurse finds out the reason for the child's visit to the health care setting.
The nurse is caring for a preschool aged child following abdominal surgery. Of the following nursing actions, which is the highest priority? The nurse uses pain assessment tools. The nurse notes any report of nausea. The nurse encourages caregivers to express concerns. The nurse documents as frequently as possible
The nurse uses pain assessment tools.
A nurse is packing a bag with all of the equipment she will need to perform a complete physical assessment at a client's home. What will the nurse need? Select all that apply. IV bag Ophthalmoscope Thermometer Tongue depressor Syringe Stethoscope
Thermometer Stethoscope Tongue depressor Ophthalmoscope
A child has been admitted to the pediatric unit with diarrhea. The nurse must collect a stool specimen for ova and parasites. The nurse knows that the proper procedure must be followed for detection of the ova and parasites. The proper procedure includes: Place the stool specimen in a sterile container. Use tongue blades to separate the stool from urine. Refrigerate the specimen until it can be taken to the laboratory. Transport the stool specimen to the laboratory promptly. Only use stool from a bed pan.
Transport the stool specimen to the laboratory promptly.
The nurse finds an elevated temperature in a blanket-wrapped infant a mother is holding and rocking. What first temperature reduction measure will the nurse take? Encourage the mother to breastfeed the infant. Administer the as-needed (PRN) antipyretic. Unwrap the infant and place the child in the crib. Reduce the room's thermostat setting.
Unwrap the infant and place the child in the crib.
How will the nurse measure urine output in the hospitalized toddler who is partially potty trained? Obtain a potty for the child and measure urine. Don gloves and press urine from training pants or diaper and measure. Weigh the wet pull-up or diaper and subtract the weight of a dry diaper. Apply a self-adhesive urine bag to the perineum.
Weigh the wet pull-up or diaper and subtract the weight of a dry diaper.
A 5-month-old is hospitalized for dehydration. What can the nurse make with items found on the unit for an activity to distract the child? color squares on paper to make a checker board a lunch bag for the child to decorate as a puppet a mobile using gauze and tongue blades modeling clay with flour, salt, and water
a mobile using gauze and tongue blades
Health care providers follow transmission-based precautions when caring for children with documented pathogens or children suspected of having highly transmissible pathogens. Which of the following are included in transmission-based precautions? protective precautions airborne precautions droplet precautions contact precautions
airborne precautions droplet precautions contact precautions
The pediatric nurse would use standard precautions in caring for which client on her floor? an adolescent who has a broken arm an infant with diarrhea a toddler with chickenpox a child who is diagnosed with pertussis
an adolescent who has a broken arm
A nursing student is learning how to insert and administer enteral feedings through a nasogastric (NG) tube. The student identifies the best way to check placement before each feeding as which of the following? x-ray aspirating stomach contents and checking pH It is not necessary to check each time. inserting air into the tube and listening for sounds in the stomach
aspirating stomach contents and checking pH
The pediatric nurse is caring for a child who is recovering after abdominal surgery several days ago. After the child's sutures are removed, the child asks the nurse, "Will my insides fall out now?" How should the nurse respond? "What make you say that?" "What do you mean by 'insides'?" "Your insides are healed and the cut you see on the outside is not what it looks like inside." "Your insides will not fall out and it is not something you need to worry about."
"Your insides are healed and the cut you see on the outside is not what it looks like inside."
A preschooler is admitted to the pediatric floor for dehydration and is frightened. Which nursing intervention would be least effective in alleviating the child's anxiety? Explain all procedures using medical terminology. Encourage a caregiver to stay with the child when possible. Assign the child to the same nurse each day. Allow the child to handle the blood pressure cuff before using it.
Explain all procedures using medical terminology.
The nurse instructs the mother of a preschool-aged child on the use of ibuprofen prescribed for a temperature. Which statement indicates that the teaching has been effective? "I should limit the child's fluids while taking this medication." "I should expect the child to complain of a stomach ache with this medication." "I should measure out the dosage using a kitchen teaspoon." "I should give this medication with food."
"I should give this medication with food."
The nursing students are learning how to perform a health assessment on a pediatric client. The nursing instructor identifies a need for further teaching when a student states: "I should take a temperature using an electronic thermometer beginning at age 3 years." "I should take blood pressure on a child beginning at age 2 years." "I should take blood pressure on a child beginning at age 3 years." "I should establish good rapport with the child's parents before beginning an assessment on a child."
"I should take blood pressure on a child beginning at age 2 years."
A 7-year-old boy has been admitted to the hospital with a diagnosis of fever of unknown origin. He has numerous tests ordered for diagnosis. When preparing him for the blood tests ordered, the best explanation would be: "The doctor needs to look at your blood to see why you are sick; it will hurt for a second." "I need to draw some blood from you. Will you hold still for me?" "The doctor needs some of your blood; trust me, it won't hurt." "The technician will draw your blood; it will just hurt for a minute."
"The doctor needs to look at your blood to see why you are sick; it will hurt for a second."
The nurse is working with a group of caregivers of children in a community setting. The topic of hospitalization and the effects of hospitalization on the child are being discussed. Which statement made by the caregivers supports the most effective way for children to be educated about hospitals? "My wife brought home several books about hospitalization and surgery, and she and I are reading them to our son." "Our next door neighbor was sick and died in the hospital. We explained to our son that usually babies are born and people get well in hospitals." "The school nurse set up posters and displays showing pictures of what the inside of a hospital looked like, and we made sure our daughter saw the display." "We are going to take our child to an open house at the hospital so she can see the pediatric unit."
"We are going to take our child to an open house at the hospital so she can see the pediatric unit."
A 4-year-old child is being prepared to undergo a bronchoscopy to remove an aspirated pea. The nurse knows that the parents need additional teaching based on which statement? "The health care provider will put a tube into my child's throat to remove the obstruction." "We will be able to take our child home immediately after the procedure is completed." "Our child will be sedated during the procedure." "We can go with our child to the holding area and stay with him until the procedure starts."
"We will be able to take our child home immediately after the procedure is completed."
The pediatric nurse is performing a health assessment on a child. Which question(s) will the nurse ask when determining the social history portion of the assessment? Select all that apply. "Can you tell me about your mommy and daddy?" "What church do you go to?" "What are your favorite foods?" "What grade are you in?" "What jobs do your mommy and daddy have?"
"What jobs do your mommy and daddy have?" "What church do you go to?"
A pediatric nurse wants to determine an accurate amount of urine output for a diapered baby. Which is the most effective method? It is impossible to get an accurate measurement of urine output in a diaper. Weigh a diaper before use and mark with weight, then weigh after and subtract the weight of the diaper. Apply a urine collection device inside the diaper and measure urine output. Count the number of wet diapers during the shift.
Weigh a diaper before use and mark with weight, then weigh after and subtract the weight of the diaper.
The nurse is conducting a health history for a 9-year-old child with stomach pains. What is a recommended guideline when approaching the child for information? Wear a white examination coat when conducting the interview. Do not make physical contact with the child during the interview. Allow the child to control the pace and order of the health history. Use quick deliberate gestures to get your point across.
Allow the child to control the pace and order of the health history.
Which approach by the nurse best demonstrates the correct way to prepare a Hispanic child for a planned hospital admission? Allow the child to put on surgical attire and "operate" on a doll to teach what will be happening. Discourage questions so as to not frighten the child. Tell the child that the procedure will not hurt because we have "magic medicine." Since the family is Hispanic, all preparation needs to be in Spanish.
Allow the child to put on surgical attire and "operate" on a doll to teach what will be happening.
When performing a physical examination on a child, the nurse notes a mirror image in the shape and position of the child's chest and abdomen. Which nursing action is appropriate? Assess the child's bowel sounds. Document the finding in the medical record. Measure each with a tape measure. Notify the primary health care provider.
Document the finding in the medical record.
When assessing heart sounds on a high school athlete, the nurse hears a "lub d-dub" sound which is associated with inspiration. What action will the nurse take? Refer the student for a stress test. Document the findings as normal. Notify the health care provider. Refer the student for an electrocardiogram.
Document the findings as normal.
A 6-week-old infant is being assessed for vision acuity. What questions should the nurse ask the parents to ascertain adequate vision? Select all that apply. Does the baby follow you with her eyes? Does the baby have any unusual eye movements? Can the baby focus on a moving object? Is there any drainage from the eyes? Do the parents have any concerns?
Does the baby follow you with her eyes? Do the parents have any concerns? Can the baby focus on a moving object?
A nurse is inspecting the surgical dressing on a school-age child and notes that there is bloody drainage on it. What actions should the nurse take? Change the dressing, initial it, then chart it. Reinforce the dressing and tape it down securely. Draw a circle around the drainage with a permanent marker, recording the date and time on it. Remove the dressing and keep it to show the physician.
Draw a circle around the drainage with a permanent marker, recording the date and time on it.
The registered nurse (RN) observes the unlicensed assistive personnel (UAP) take a rectal temperature on a 6-month-old client diagnosed with diarrhea. Which action by the RN is appropriate? Complete an error report on the UAP's action. Reassess the client's temperature with a tympanic thermometer. Notify the unit manager of the UAP's action. Educate the UAP on when to avoid taking rectal temperatures.
Educate the UAP on when to avoid taking rectal temperatures.
A preschooler is admitted to the pediatric floor for dehydration and is frightened. Which nursing intervention would be least effective in alleviating the child's anxiety? Explain all procedures using medical terminology. Encourage a caregiver to stay with the child when possible. Allow the child to handle the blood pressure cuff before using it. Assign the child to the same nurse each day.
Explain all procedures using medical terminology.
A nurse is caring for a 14-year-old with a gastrostomy tube. The girl has skin breakdown and irritation at the insertion site. What would be the most appropriate method to clean and secure the gastrostomy tube? Place a transparent dressing over the site whether there is drainage or not. Make sure the tube cannot be moved in and out of the child's stomach. If any drainage is present, use a presplit 2 × 2 and place it loosely around the site. Use adhesive tape to tape the tube in place and prevent movement.
If any drainage is present, use a presplit 2 × 2 and place it loosely around the site.
A preschool-aged child has not been able to eat for several days until all diagnostic tests are complete to determine the cause of chronic diarrhea. Which nursing diagnosis should the nurse identify as being appropriate for the client at this time? Imbalanced nutrition, less than body requirements, related to food restriction for procedures Deficient diversionary activity related to hospitalization and frequent procedures Fear related to new and strange surroundings of procedure rooms Risk for injury related to intrusive procedures
Imbalanced nutrition, less than body requirements, related to food restriction for procedures
A nurse is taking a health history on a new family at the pediatric clinic. Which information is the priority information to gather for a complete history database? Immunization record Recent or past hospitalizations Past accidents the child was involved in Coping strategies of the child
Immunization record
The nurse is teaching the student nurse how to perform a physical assessment based on the child's developmental stage. Which statement accurately describes a recommended guideline for setting the tone of the examination for a school-age child? Keep up a running dialogue with the caregiver, explaining each step as you do it. Include the child in all parts of the examination; speak to the caregiver before and after the examination. Address the child by name; speak to the caregiver and do the most invasive parts last. Speak to the child using mature language and appeal to his or her desire for self-care.
Include the child in all parts of the examination; speak to the caregiver before and after the examination.
A 6-year-old with leukemia is placed on reverse isolation. What nursing actions could prevent depression and loneliness in this client? Select all that apply. Read a story while in the room. Play a game while in the room. Quickly exit the room when possible. Spend extra time to talk while in the room. Do all nursing tasks at one time.
Spend extra time to talk while in the room. Read a story while in the room. Play a game while in the room.
A nurse is administering a bolus nasogastric (NG) feeding to a child who begins gasping, coughing, and developing cyanosis. What is the first action that the nurse should take after this observation? Aspirate gastric contents and measure the pH to be sure the placement is correct. Stop the feeding and withdraw the tube. Pull out a small amount of the tube and reposition. Call the physician.
Stop the feeding and withdraw the tube.
A nurse working with a client who has an elevated temperature notices that the child is beginning to shiver. Which of the following should the nurse do immediately? Lower the room temperature. Apply cool compresses. Remove more clothing. Stop whatever intervention is being done to lower the temperature.
Stop whatever intervention is being done to lower the temperature.
To obtain an accurate heart rate in an infant, what would be most important for the nurse to do? Use an electronic stethoscope. Take a radial pulse. Take the apical pulse. Count the pulse rate for 30 seconds.
Take the apical pulse.
How does the nurse know that the expected outcome(s) for the child undergoing a magnetic resonance imaging (MRI) procedure has been met? Select all that apply. The child was able to remain still throughout the procedure. The child was able to describe the procedure before going. The child was able to tolerate the procedure using earplugs. The child's parents were able to go with the child to the procedure holding area. The child removed all metal objects prior to the procedure.
The child was able to describe the procedure before going. The child removed all metal objects prior to the procedure. The child was able to remain still throughout the procedure. The child was able to tolerate the procedure using earplugs. The child's parents were able to go with the child to the procedure holding area.
The nurse is ordered to apply restraints to a toddler who keeps pulling at the tubes in his arm. Which criteria must occur to ensure proper use of these restraints? Select all that apply. The nurse must check the restraints every 15 minutes while they are in place. Remove the restraint every 2 hours to allow for range of motion and repositioning. Use a clove-hitch type of knot to secure the restraints with ties. Assess the temperature of the affected extremities, pulses, and capillary refill every 15 minutes after placement. Secure the restraints with ties to the side rails, not the bed or crib frame. Encourage parent participation, providing continuous explanations about the reasons and time frame for restraints.
Use a clove-hitch type of knot to secure the restraints with ties. Remove the restraint every 2 hours to allow for range of motion and repositioning. Encourage parent participation, providing continuous explanations about the reasons and time frame for restraints.
The public health nurse is choosing to focus community education for parents of young children about awareness of the hospital. When is the best time to educate the children about the hospital? When the children are capable of understanding death and dying When the children begin to show interest in emergency vehicles When the children begin to recognize emergency workers When the children are capable of understanding basic functions of community resources
When the children are capable of understanding basic functions of community resources
Which intervention is most important in assuring a child's cooperation and reducing his or her fear during an emergency room visit? having the parent stay with the child allowing the child to draw and color while in the emergency room providing distractions for the child during all procedures offering the child a popsicle for being good
having the parent stay with the child
A school-aged child needs to have an IV started. Where would be the best place for the nurse to perform this procedure? in the playroom where there are distractions in the child's room, ensuring privacy off the floor in a procedural suite in a treatment room
in a treatment room
A nurse is preparing to apply heat therapy to a client who has a back abscess. Heat has which of the following benefits? Select all that apply. causes vasoconstriction promotes muscle relaxation increases circulation causes vasodilation prevents drainage of abscess
increases circulation causes vasodilation promotes muscle relaxation
The nurse is preparing to start an intravenous (IV) line on a stable pediatric client in the hospital. Which location is most appropriate for the nurse to use for this procedure? the unit's playroom the pediatric treatment room room selected by the client the child's hospital room
the pediatric treatment room
