Pediatrics Exam II --- Canvas & ATI Quizzes

A nurse is admitting a child who has leukemia and a critically low platelet count. Which of the following precautions should the nurse initiate?

Bleeding; The nurse should initiate bleeding precautions for a child who has a low platelet count. Bleeding precautions involve specific measures to reduce the risk of bleeding, such as using soft-bristled toothbrushes, avoiding IM injections, and preventing constipation.

A nurse is assessing an adolescent who experienced blunt trauma to the abdomen. Which of the following findings is the nurse's priority?

Blood pressure 92/50 mmHg; The expected reference range for blood pressure in an adolescent is 110/65 to 120/80 mmHg. A blood pressure 92/50 mmHg indicates the adolescent is hypotensive and unstable. Therefore, this finding is the priority. Blunt abdominal trauma can cause internal hemorrhage that leads to hypotension.

A nurse is preparing to administer digoxin to a 6 month old infant. Prior to administering the dose, the nurse measures the apical heart rate. The nurse should withhold the dose if the infant's apical heart rate is less than what rate?

Bradycardia is an adverse effect of digoxin. Expected apical heart rate vary considerably according to age. The nurse should withhold the digoxin dose for heart rate of 60/min or below in an adult, 70/min or below in a child, and 90/min or below in an infant.

A nurse is preparing to administer digoxin to a 6 month old infant. Prior to administering the dose, the nurse measures the apical heart rate. The nurse should withhold the dose if the infant's apical heart rate is less than what rate?

Bradycardia is an adverse effect of digoxin. Expected apical heart rates vary considerably according to age. The nurse should withhold the digoxin dose for heart rate of 60/min or below in an adult, 70/min below in a child, and 90/min or below in an infant.

A nurse is caring for a 6 month old who has a cardiac catheterization. Which of the following should the nurse plan to include in the discharge teaching? The nurse should plan to include _________ and _________ in the discharge instructions for the guardians.

Call provider is right leg feels cool to the touch in comparison to left leg. Administer acetaminophen or ibuprofen oral solution for pain as needed.

A nurse is caring for a child who has Kawasaki disease. Which of the following systems should the nurse monitor in response to this diagnosis?

Cardiovascular changes occur in children who have Kawasaki disease due to inflammation of the arterioles, venules, and capillaries.

A nurse is caring for a child who has a tracheostomy. After suctioning the tracheostomy, the nurse should use which of the following findings to determine that the procedure was effective?

Clear breath sounds; Clear breath sounds indicate that there are no remaining secretions obstructing or potentially obstructing the client's airway.

A nurse is caring for a child who is 2 hours postoperative following a tonsillectomy. Which of the following fluid items should the nurse offer the child at this time?

Crushed ice; Cold, clear liquids are well-tolerated following a tonsillectomy. Liquids that are brown or red should be avoided in order to tell the difference between the liquid and fresh or old blood.

A nurse is caring for a school-age child who has mild persistent asthma. Which of the following is an expected finding? SATA

Daytime symptoms occur more than twice per week is correct; A child who has mild persistent asthma will typically have daytime symptoms more than twice per week, but not daily. Minor limitations occur with normal activity is correct; A child who has mild persistent asthma will have some minor limitations with normal daily activities. Peak expiratory flow (PEF) is greater than or equal to 80% of the predicted value is correct; A child who has a mild persistent asthma will have a PEG greater than or equal to 80% of the predicted value.

A nurse is caring for a toddler who has acute laryngotracheobronchitis and has been placed in a cool mist tent. Which of the following findings indicates that the treatment has been effective?

Decreased stridor; Laryngotracheobronchitis, or croup, is a condition caused by an infection of the upper airway (larynx, trachea, and bronchus) and is characterized by a barking cough. Edema and obstruction in the upper airways cause the characteristic cough and stridor (noisy breathing). The direct purpose of a cool mist tent is to humidify the inspired air, which decreased respiratory effort.

A nurse is preparing to begin chest compressions on an infant. The nurse should perform compressions using which of the following techniques?

Deliver compressions at 1/3 the depth of the chest; The proper depth of chest compressions for an infant is 1/3 the depth of chest, which is approximately 1.5 inches.

A nurse is caring for a 6 month old infant who is postoperative following a myringotomy. Which of the following pain scales should the nurse use to determine the infant's pain level?

FLACC; The FLACC pain scale is appropriate to use with infants and children between the ages of 2 months and 7 years.

A nurse is providing discharge instructions to the parent of a 10 year old child following a cardiac catheterization. Which of the following instructions should the nurse include?

Give the child acetaminophen for discomfort; The child might have minor discomfort at the puncture site. The parents should offer either acetaminophen or ibuprofen due the risk of Reye Syndrome associated with taking aspirin.

A nurse in a pediatric clinic is caring for a child who has iron deficiency anemia and a new prescription for ferrous sulfate tablets. Which of the following instructions should the nurse provide the parents regarding administration of this medication?

Give with orange juice; Citrus fruit or juice aids in absorption of this medication.

An infant with bronchiolitis caused by respiratory syncytial virus (RSV) is admitted to the pediatric unit. What does the nurse expect the prescribed treatment to include?

Humidified cool air and adequate hydration are essential to facilitating improvement in the child's physical status. Postural drainage is not effective with this disorder; oxygen is used only if the infant has severe dyspnea and hypoxia. Bronchodilators are not used, because the bronchial tree is not in spasm; cough suppressants are ineffective. Corticosteroids are ineffective; antibiotics are also ineffective, because the causative agent is viral.

A nurse on a cardiac unit is caring for a preschooler. Drag words from the choices below to fill in each blank in the following sentence. The client is at risk for developing __________ and __________.

Hypokalemia & Digitalis toxicity; The client is receiving furosemide every 6 hours. Furosemide causes potassium depletion. The client is receiving digitalis every 12 hours. The margin of safety is very small, 0.8 to 2 mcg/L.

A nurse on a cardiac care unit is caring for a preschooler. Drag words from the choices below to fill in each blank in the following sentence. The client is at risk for developing __________ and __________.

Hypokalemia & Digitalis toxicity; The client is receiving furosemide every 6 hours. Furosemide causes potassium depletion. Therefore, the client is at risk for hypokalemia. The client is receiving digitalis every 12 hours. The margin of safety is very small, 0.8 to 2 mcg/L.

A nurse is assessing a 3 year old child who has aortic stenosis. Which of the following findings should the nurse expect?

Hypotension; Result of decreased cardiac output Weak pulses; Result of decreased cardiac output Murmur; Narrowing of the aortic valve cause a characteristic murmur in children who have AS.

A nurse is planning care for an adolescent who is postoperative following scoliosis repair with Harrington rod instrumentation. Which of the following interventions should the nurse include in the plan of care. a. Keep the head of the bed at a 30 degree angle b. Reposition the the client by log rolling every 4 hours c. Place the client in protective isolation d. Initiate the use of a PCA pump for pain control

Initiate the use of a PCA pump for pain control; The nurse should initiate the use of a PCA pump for an adolescent who is postoperative following scoliosis repair. The PCA pump allows the client to control the delivery of pain medications.

An infant is admitted to the pediatric unit with bronchiolitis caused by respiratory syncytial virus (RSV). What interventions are appropriate nursing care for the infant? Select all that apply.

Instilling saline nose drops Maintaining contact precautions Suctioning mucus with a bulb syringe Saline nose drops help clear the nasal passage, which improves breathing and aids the intake of fluids. RSV is contagious; infants with RSV should be isolated from other children, and the number of people visiting or caring for the infant should be limited. Infants with RSC produce copious amounts of mucus, which hinders breathing and feeding; suctioning before meals and at naptime and bedtime provides relief. Fluid intake should be increased; adequate hydration is essential to counter fluid loss. These infants have difficulty nursing and often vomit their feedings. If measures such as suctioning before feeding and instilling saline nose drops are ineffective, intravenous fluid replacement is instituted. The humidified oxygen should be cool. It relieves the dyspnea and hypoxia that is prevalent in infants with RSV.

A nurse is caring for a toddler whose parent states while bathing the child she noticed a mass in his abdominal area and that his urine is a pink color. Which of the following actions is the nurse's priority?

Instruct the parent to avoid pressing on the abdominal area; The priority action is to instruct the parent to avoid pressure on the child's abdomen. These symptoms are associated with Wilm's tumor, and trauma to the mass should be avoided to prevent movement of cancer cells into other sites.

A nurse is reviewing the laboratory results of four children. Which of the following values should the nurse report to the provider?

Iron 38 mcg/dL; This iron level is below the expected reference range for children and should be reported to the provider.

A 6-month-old infant is brought to the emergency department in severe respiratory distress. A diagnosis of respiratory syncytial virus (RSV) infection is made, and the infant is admitted to the pediatric unit. What should be included in the nursing plan of care?

Maintain standard and contact precautions; RSV is highly contagious. The infant should be isolated or placed with other infants with RSV. Standard and contact precautions are instituted to limit the spread of pathogens to others. The infant should receive cool, humidified oxygen by nasal cannula or mark or in a croup tent. Because RSV is extremely contagious, the number of visitors should be limited. Uninfected children should not be allowed near the infant, and as few personnel as possible should care for the infant. Antibiotics are not effective against RSV, and their use is contraindicated.

A nurse is creating a plan of care for a child who has sickle cell anemia. Which of the following interventions should the nurse include in the plan?

Observe for indication of hypokalemia; The nurse should observe the child for indications of hypokalemia. Diuresis can result in electrolyte loss, leading to hypokalemia.

A nurse is caring for an adolescent in an emergency department. The nurse reports the 2400 assessment findings to the provider. Which of the following should the nurse anticipate the provider will prescribe? Indicate if the potential prescription is anticipated or contraindicated for the client.

Obtain blood cultures x3 is anticipated. Obtain an electrocardiogram is anticipated. Restrict dental hygiene is contraindicated. Administer antibiotic therapy is anticipated. Perform strenuous exercise regimen twice daily is contraindicated.

A nurse is assessing a toddler who has heart failure. Which of the following should the nurse expect?

Orthopnea; A toddler who has heart failure has increased venous return to the heart and lungs, which leads to pulmonary congestion. The congestion causes orthopnea, or difficulty breathing, while lying down. Having teh toddler sit up decreases venous return, as well as pressure the abdominal organs have on the diaphragm. This decrease in pressure improves breathing and oxygenation.

A nurse is assessing a child who is in sickle cell crisis. Which of the following findings should the the nurse expect?

Pain; resulting from tissue hypoxia and necrosis

A nurse is caring for an infant who has a congenital heart defect. Which of the following defects is associated with increased pulmonary blood flow?

Patent ductus arteriosus

A nurse is caring for an infant who has a congenital heart defect. Which of the following defects is associated with increased pulmonary blood flow?

Patent ductus arteriosus; With PDA, the area between the pulmonary artery and aorta remains open, allowing the blood to flow through the patent ductus arteriosus and back to the pulmonary artery and lungs.

A nurse manager is providing a class on cystic fibrosis for the pediatric staff nurses. Physiologic adaptations to cystic fibrosis are a result of which problem?

Pathology of mucus-secreting glands; Cystic fibrosis is a genetic disorder affecting all mucous-secreting (exocrine) glands. A swear gland abnormality is not involved in cystic fibrosis; children with cystic fibrosis lose excessive amounts of sodium through perspiration caused by exocrine gland dysfunction. Cilia action may be influenced by thickened secretions, but the cilia are not affected by cystic fibrosis. Exocrine, not endocrine, glands are involved in cystic fibrosis.

A nurse is planning care for a child who has suspected epiglottitis. Which of the following actions should the nurse take?

Place the child in an upright position; Placing the child in an upright position will assist in maintaining a patent airway.

A nurse is caring for an adolescent following a cardiac catheterization. Which of the following assessment findings should the nurse report to the provider?

Pressure dressing indicating blood loss from the arterial puncture site. Blood pressure decreasing from 120/76 to 100/52. Pain increasing from 0-10. Apical pulse above reference range & Right lower extremity color and warmth.

A nurse is caring for an infant who has congenital heart disease. Which of the following actions should the nurse plan to take?

Provide 100% oxygen by face mask is correct. Place the infant in a knee-chest position is correct. Administer morphine via IV bolus is correct.

A nurse is caring for an infant who has congenital heart disease. Which of the following actions should the nurse take? For each nursing action, click to specify if the action is indicated or contraindicated for the client.

Provide 100% oxygen by face mask is indicated. Prepare to assist with the insertion of a chest tube is contraindicated. Place the infant in a knee-chest position is indicated. Request a prescription for a diuretic is contraindicated. Perform nasopharyngeal suctioning for a maximum of 5 seconds is contraindicated. Administer morphine via IV bolus is indicated.

Several hours after admission of a child to the pediatric unit with laryngotracheobronchitis (viral croup), the nurse determines that tachypnea and tachycardia, accompanied by intercostal and substernal retractions and increased restlessness, have developed. What is the priority nursing action?

Reporting the respiratory status to the practitioner; These are signs of increasing hypoxia; intubation may be necessary to maintain an open airway. The signs are not indicative of increased secretions; suctioning could precipitate sudden laryngospasm. Striking the back is ineffective against laryngeal spasms. The inflammation is preventing the oxygen from reaching the lungs; increasing the amount of oxygen will not be effective until the inflammation is reduced.

A nurse is caring for a school age child. Which of the following assessment findings should the nurse report to the provider? Select the 4 findings that the nurse should report to the provider.

Respiratory effort is correct. Oxygenation is correct. Pain is correct. Blood pressure is correct.

A nurse is caring for a adolescent who presents to the ED. The nurse reassesses the adolescent at 1930. For each assessment finding, click to specify if the finding indicates that the adolescent's condition has improved, has not changed, or has declined.

Respiratory rate has improved. Oxygen saturation has improved. Oral intake has improved. Lung sounds have not changed. Heart rate has improved. Dyspnea has not changed. Blood pressure has improved.

A nurse is assessing a 3 year old child at a routine wellness checkup. Which of the following findings should the nurse expect?

Stands on one foot for a few seconds; The nurse should expect a 3 year old child to be able to stand on one foot for a few seconds, ascend stairs on alternate feet, and jump off the bottom step.

Which assessment findings should the nurse expect when caring for a child with cystic fibrosis? (Select all that apply.)

Steatorrhea Foul-smelling stools Delayed growth Pulmonary congestion Weight loss, not weight gain, is associated with cystic fibrosis. The other answers are all common assessment findings in the client with cystic fibrosis.

A nurse is performing a respiratory assessment of an 8-month-old child with the diagnosis of viral pneumonia. The nurse identifies bronchial breath sounds over areas of consolidation, mild substernal retractions, profuse mucus production, pallor, and a temperature of 102° F (38.9° C). What is the priority nursing action?

Suctioning the nasopharynx so a patent airway can be maintained; Establishment and maintenance of a patent airway is always the priority. This intervention follows the ABCs of emergency care. An intravenous infusion will likely be started; however, this is not essential right away. The practitioner, not the respiratory therapist, should be asked for a prescription to begin oxygen administration; this action is not the priority. Taking the time to obtain a prescription for an antipyretic will delay attention to the immediate problem of respiratory distress.

A nurse is caring for a 4 year old child who has an atrial septal defect (ASD). Which of the following assessment findings at 1600 indicate that the expected outcomes have been met?

Temperature 36.5 C (97.7 F). Right groin pressure dressing is intact and has a small amount of dried blood on the dressing. Right leg is warm to the touch and equal in color to the left leg. Pedal and popliteal pulses strong and equal in bilateral lower extremities. Apical heart rate is strong and regular.

A nurse on a pediatric unit is assessing a 1 month old infant. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

The nurse should administer prostaglandin E1 and prepare the infant for an arterial switch because this infant is most likely experiencing transposition of the great vessels, which has caused heart failure because the infant has a gallop rhythm, tachycardia, tachypnea at rest, decreased SPO2, cyanosis, prolonged capillary refill time, and cool extremities. The nurse should monitor the infants urine output and daily weight to assess for manifestations of worsening heart failure.

A nurse in the emergency department is caring for a 2 year old. Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

The nurse should administer steroids and racemic epinephrine because the child is most likely experiencing acute laryngotracheobronchitis. The nurse should monitor the child's oxygen saturation and respiratory status in order to measure the child's response to treatment.

A nurse is caring for a 6 week old infant who has a ventricular septal defect (VSD). Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

The nurse should assess the apical pulse for 1 full minute and assess the rhythm strip for a prolonged P-R interval because the infant is most likely experiencing digoxin toxicity. The manifestations of digoxin toxicity that are see in infants most commonly include vomiting, poor feeding, and bradycardia. The P-R interval is also prolonged if digoxin toxicity is occurring. It is critical the nurse quickly identified and reports these symptoms to the provider for treatment of digoxin toxicity. Furosemide is a potassium wasting diuretic and can cause hypokalemia. Hypokalemia increases the potential for digoxin toxicity. The nurse should continue to monitor the infant's heart rate and withhold digoxin per the provider's prescription. It may be necessary to treat the digoxin toxicity with the antidote digoxin immune fab fragment. It is important to continue to monitor digoxin level as treatment is initiated.

A nurse is caring for a 6 week old infant who has a ventricular septal defect (VSD). Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress.

The nurse should assess the apical pulse for 1 full minute and assess the rhythm strip for a prolonged P-R interval because the infant is most likely experiencing digoxin toxicity. The manifestations of digoxin toxicity that are seen in infants most commonly include vomiting, poor feeding, and bradycardia. The P-R interval is also prolonged if digoxin toxicity is occurring. It is critical the nurse quickly identified and reports these symptoms to the provider for treatment of digoxin toxicity. Furosemide is a potassium wasting diuretic and can cause hypokalemia. Hypokalemia increases the potential for digoxin toxicity. The nurse should continue to monitor the infant's heart rate and withhold digoxin per the provider's prescription. It may be necessary to treat the digoxin toxicity with the antidote digoxin immune fab fragment. It is important to continue to monitor digoxin level as treatment is initiated.

A nurse is preparing to administer a vaccine into the deltoid muscle of a preschooler. Which of the following actions should the nurse take?

Use a 1.8 mm (0.5in) needle; The nurse should use the smallest size needle that will allow the medication to pass through the subcutaneous tissue and enter the muscle. For a preschooler, a 1.9 mm (0.5 in) needle is adequate in length.

The nurse is providing care to an infant who is diagnosed with bronchiolitis. Which breath sounds indicate the infant is experiencing respiratory distress? Select all that apply.

Wheezing & Grunting; Wheezing and grunting are adventitious respiratory sounds that indicate respiratory distress in the neonate. Tachypnea is the term used to indicate a respiratory rate of greater than 60 breaths per minute in an infant. While this does indicate respiratory distress, tachypnea is not a type of breath sound. Retractions, or the use of accessory muscles, are indicative of respiratory distress in the neonate, but this is not a type of breath sound.

A nurse is preparing to discharge a child who has a new prescription for an oral antibiotic. Which of the following should the nurse include in the discharge instructions? SATA a. The reason why the child is taking a medication b. Written information about the medication c. Stopping the medication when the child feels better d. The adverse effect of the medication e. Using a kitchen spoon to administer the medication

a, b, & d

A child with a diagnosis of tetralogy of Fallot exhibits an increased depth and rate of respirations. On further assessment, the nurse notes increased hypoxemia. The nurse interprets these findings as indicating which situation? a. A hypercyanotic episode b. Anxiety c. Temper tantrum d. The need for immediate health care provider information

a. A hypercyanotic episode Rationale: Children with tetralogy of Fallot or similar physiology may experience hypercyanotic episodes, or tet spells. These episodes are characterized by increased respiratory rate and depth and increased hypoxia. Immediate HCP notification is not required unless other appropriate nursing interventions are unsuccessful.

The nurse is planning care for a preschooler with Kawasaki disease. Which intervention should the nurse plan to implement? a. Administering intravenous immune globulin (IVIG) as prescribed b. Restricting fluids, especially fruit juices c. Ensuring bright lighting in the room during assessments d. Administering penicillin G benzathine (Bicillin) as prescribed

a. Administering intravenous immune globulin (IVIG) as prescribed Rationale: Kawasaki disease is treated with high-dose IVIG in combination with aspirin to lower the risk of coronary artery abnormalities. A clinical manifestation of bilateral non-purulent conjunctivitis occurs with Kawasaki disease, so the nurse should avoid bright overhead lights. Nursing care is focused on adequate hydration, so fluids should not be restricted and fruit juices are not contraindicated. Kawasaki disease is an acute febrile exanthematous illness of children with a generalized vasculitis of unknown origin. It is not an infectious disease, so antibiotics (penicillin) are not administered

A 5-year-old child undergoes cardiac catheterization. The child is in the post-cardiac catheterization unit for 2 hours when the incoming nurse receives the report from the outgoing nurse. Which part of the child's report should the incoming nurse question? a. Bed rest with bathroom privileges b. Vital signs every 30 minutes c. Voided 100 mL since admission d. Pressure dressing over entry site

a. Bed rest with bathroom privileges Rationale: Children are kept on complete bed rest for 4 to 6 hours after cardiac catheterization to reduce the risk of bleeding or trauma at the insertion site; the report regarding bathroom privileges should be questioned. Frequent assessment of vital signs is part of routine post-catheterization care. Urine output is 100 mL is within acceptable limits for a child of this age; oral fluids are encouraged to promote hydration and urination. A pressure dressing is placed over the insertion site to prevent bleeding. This is routine post-catheterization care.

The parent of a 5-month-old infant with heart failure questions the necessity of weighing the baby every morning. What does the nurse say that this daily information is important in determining? a. Fluid retention b. Kidney function c. Nutritional status d. Medication dosage

a. Fluid retention Rationale: Fluid retention is reflected by an excessive weight gain in a short period. Inadequate cardiac output decreases blood flow to the kidneys and thus leads to increased intracellular fluid and hypervolemia. Although this assessment may add information to the data regarding kidney function, other assessments, such as hourly urine output, blood urea nitrogen concentration, and creatinine level more significantly reflect kidney function. Weight gain resulting from nutritional intake is gradual and will vary greatly on a day to day basis. Although weight is used to determine medication dosages, dosages do not need to be recalculated according to changes in daily weights.

A 1-year-old child has a congenital cardiac malformation that causes right-to-left shunting of blood through the heart. What clinical finding should the nurse expect? a. Increased hematocrit b. Proteinuria c. Peripheral edema d. Absence of pedal pulses

a. Increased hematocrit Rationale: Polycythemia, reflected in an increased hematocrit reading, is a direct attempt by the body to compensate for the decrease in oxygen to all body cells caused by the mixture of oxygenated and deoxygenated circulating blood. Proteinuria is not a characteristic of heart malformations that cause right to left shunting of blood; nor is edema. An absence of pedal pulses is characteristic of coarctation of the aorta, an obstructive malformation.

A 3-year-old child is scheduled for cardiac catheterization. What is the priority nursing care after this procedure? a. Monitoring the site for bleeding b. Encouraging early ambulation c. Restricting fluids until the blood pressure has stabilized d. Comparing blood pressure readings in the lower extremities

a. Monitoring the site for bleeding Rationale: Hemorrhage is a major life-threatening complication because arterial blood is under pressure and a catheter has been inserted into an artery. The child is kept in bed for 6 to 8 hours after an arterial catheterization. Fluids may be given as soon as they are tolerated. Pulses, not blood pressure, must be compared for quality and symmetry.

A 4-year-old child is undergoing a diagnostic workup for pulmonic stenosis. The mother asks the nurse about the diagnosis. How does the nurse describe pulmonic stenosis? a. Narrowing of the valve between the right ventricle and the pulmonary artery b. Narrowing of the valve between the left atrium and left ventricle c. Hardening of the valve between the right atrium and right ventricle d. Hardening of the valve between the right ventricle and the arch of the aorta

a. Narrowing of the valve between the right ventricle and the pulmonary artery Rationale: The pulmonic valve is located between the right ventricle and pulmonary artery. The cusps of the valves may be fused, or the infundibulum below may be hypertrophied, thereby restricting blood flow to the lungs. The mitral, tricuspid, and aortic valves are not involved in pulmonic stenosis.

An infant with a congenital heart defect is returned to the unit after cardiac catheterization. The nurse manager is observing a nurse newly assigned to the unit. Which nursing intervention should the nurse manager interrupt? a. Performing range-of-motion exercises b. Offering fluids and foods as tolerated c. Monitoring the apical pulse for rate and rhythm d. Assessing the pulses distal to the catheterization site

a. Performing range-of-motion exercises Rationale: ROM exercises of the limb bearing the catheterization site might cause the dislodgement of a clot and result in hemorrhage. Intake should start with fluids and progress as tolerated. The apical pulse is monitored because a common complication after cardiac catheterization involves disturbances of cardiac rate and rhythm. The peripheral pulses are assessed because formation of thrombi is a complication of cardiac catheterization

What findings should a nurse expect when examining the laboratory report of a preschooler with rheumatic fever? a. Positive antistreptolysin titer b. Negative C-reactive protein c. Increased reticulocyte count d. Decreased sedimentation rate

a. Positive antistreptolysin titer Rationale: A positive antistreptolysin titer is present with RF because of the previous infection with streptococci. An increased reticulocyte count is usually related to a decrease in mature red blood cells caused by hemorrhage or blood dycrasias; it is unrelated to an infectious

A 4-month-old infant is admitted to the pediatric unit with a diagnosis of congestive heart failure. Which nursing assessment would most accurately demonstrate improvement in the infant's condition? a. Weight loss during next 2 days b. Decreased tremors c. Increased hours of sleep d. More rapid heart rate within 2 days

a. Weight loss during next 2 days Rationale: Weight loss indicates fluid loss. Water retention is a classic sign of CHF. Tremors are not typical in infants with heart disease. Tremors are related to CNS irritability. If the infant's condition improved, energy would increase and sleeping needs would decrease. Tachycardia is a sign of CHF. The purpose of the cardiotonic is to slow the heart rate.

A nurse is teaching the mother of a child who has cystic fibrosis and has a prescription for pancreatic enzymes three times per day. Which of the following statements indicate that the mother understands the teaching? a. "My child will take the enzyme to improve her metabolism." b. "My child will take the enzymes following meals." c. "My child will take the enzymes to help digest the fat in foods." d. "My child will take the enzymes 2 hours before meals."

c. "My child will take the enzymes to help digest the fat in foods."; Pancreatic enzymes help the body to digest the fat in foods.

A nurse is caring for a toddler who is 24 hours postoperative following a cleft palate repair. Which of the following actions should the nurse take? a. Offer fluids through a straw b. Apply bilateral wrist restraints c. Administer opioids for pain d. Implement a soft diet

c. Administer opioids for pain; Administering opioids for pain is an appropriate action by the nurse. Opioids control pain in the immediate postoperative period are followed by the administration of acetaminophen PRN.

A nurse is providing teaching to a 17 year old female client who has severe acne about the use of isotretinoin. Which of the following adverse 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. Feelings of isolation; Feelings of isolation can indicate suicide ideation, which can lead to self-harm. Therefore, this adverse effect is the priority to report to the provider.

A nurse is providing education to a school age child who has a new diagnosis of asthma. Which of the following statements should the nurse include in the teaching?

"Avoid triggers that cause an attack." The nurse should emphasize that the ability to prevent asthma attacks can be improved by avoiding allergens that the child is sensitive to. Triggers can include animals, dust, certain foods, pollens, and grass. Clients who have asthma manifestations throughout the year should receive allergy testing to determine specific triggers.

A nurse is obtaining a health history from a child who has suspected acute rheumatic fever. Which of the following questions should the nurse ask?

"Has your son had a sore throat recently?" Rheumatic fever typically develops 2 to 6 weeks after untreated or ineffectively treated streptococcal infection of the respiratory tract. It is appropriate to determine whether the child previously had a sore throat.

A nurse receives a call from a parent of a child who has von Willebrand disease and was having a nosebleed. Which of the following instructions should the nurse give to the parent?

"Have your child sit with her head tilted forward and hold pressure on her nose for 10 minutes." The nurse should instruct the parent to have the child sit up with her head tilted forward to reduce the risk of aspiration. The parent should apply pressure with the thumb and forefinger to the child's nose for 10 min and then check for further bleeding.

A nurse is teaching a parent of an infant who has heart failure about meeting the infants's nutritional needs. Which response indicates an understanding of the teaching?

"I will add Polycose to each of my baby's bottles." The parent should add Polycose to the formula to increase the number of calories per ounce, allowing the infant to consume more calories in less volume.

A nurse is teaching a parent of a child who has hemophilia how to control a minor bleeding episode. Which of the following statements by the parent indicates a need for further teaching?

"I will apply heat." Supportive measures to control a minor bleeding episode include applying cool compresses

A nurse is providing teaching about self-administration of insulin to the parent of a school-age child who has a new of diabetes mellitus. Which of the following statement by the parent indicates a need for further teaching?

"I will be sure my child aspirates before injecting the insulin."; It is not necessary to aspirate before injecting the insulin

A nurse is providing teaching about self-administration of insulin to the parent of a school-age child who has a new of diabetes mellitus. Which of the following statements by the parent indicates a need for further teaching?

"I will be sure my child aspirates before injecting the insulin."; is not necessary to aspirate before injecting the insulin.

A nurse is teaching the mother of a 5 year old child who has cystic fibrosis about pancreatic enzymes. The nurse should understand that further teaching is necessary when the mother states which of the following?

"I will give my son the enzymes between meals."

A nurse is discharging a child who has sickle cell anemia after an acute crisis episode. Which of the following instructions should the nurse include in the teaching?

"Offer fluids to your child multiple times ever day." Preventing dehydration is an important step in preventing a sickle cell crisis. The nurse should provide the parents with a specific fluid goal for the child to reach each day.

A nurse is providing teaching to the parents of a child who has iron deficiency anemia and is taking iron supplements. Which of the following statements by the parents indicates an understanding of the teaching?

"Our child's blood count will need to be monitored routinely for several weeks." The child's response to treatment will be determined by monitoring hemoglobin and hematocrit levels through routine blood tests. Treatment can take up to 3 months to be effective.

A nurse is obtaining vital signs from a 2 month old infant. The infant's heart rate is 190/min and his temperature is 40 C (104 F). The father asks the nurse why the infant's heart is beating so fast. Which of the following responses by the nurse is appropriate?

"The fever is causing an increase in your baby's heart rate." The expected reference range for temperature of an infant from birth to 1 year is 36.5C (97.7F) to 37.2C (98.9F). This infant has a fever that is causing the infant's heart rate to increase. The expected reference range for heart rate is a 2 month old infant is 121 to 179/min.

A nurse is teaching an assistive personnel to measure a newborn's respiratory rate. Which of the following statements indicates an understanding of why the respiratory rate should be counted for a complete minute?

"The rate and rhythm of breath are irregular in newborns."; Newborns have an irregular respiratory rate and rhythm. Therefore, counting the respiratory rate for a complete minute is recommended to obtain an accurate rate.

A nurse is administering ear drops to a toddler and pulls the auricle down and back. The mother asks, "Why are you pulling the ear that way?" Which of the following explanations should the nurse provide?

"This technique opens the ear canal, allowing medication to reach the inner ear region."; For children younger than 3 years old, the auricle should be pulled down and back to fully open the ear canal. This technique allows the correct dose of medication to enter the ear.

A nurse is caring for a child who was admitted with suspected rheumatic fever. The provider prescribes an anti-steptolysin O (ASO) titer. The parent asks the nurse the purpose of the test. Which of the following responses should the nurse make?

"This test will confirm if your child had a recent streptococcal infection." An ASO titer is a blood test that measures anti-streptolysin O antibodies in the blood. The test determines if the client has recently been infected with Group A streptococcus. The ASO antibody can be detected in the blood for weeks or months after the primary source of the infection has been eradicated.

A nurse is preparing to administer acetaminophen 10 mg/kg/dose to a child who weighs 28 lb. The amount available is acetaminophen 120 mg/5mL. How many mL should nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)

5.3 mL

A nurse is reviewing data for four children. Which of the following children should the nurse assess first?

A 10 year old child who has sickle cell anemia who reports severe chest pain; When using the urgent vs non-urgent approach to client care, the nurse should determine that the 10 year old child who has sickle cell anemia and reports severe chest pain should be assessed first. This finding is a medical emergency because it is a manifestation of acute chest syndrome.

A nurse is caring for a group of adolescents. Which of the following should be reported to the provider immediately?

A client's blood pressure changes from 112/60 mmHg to 90/54 mmHg when standing; Vital sign ranges for adolescents are similar to those for adults. A drop in the systolic blood pressure of more than 20 mmHG or a drop in the diastolic of more than 10 mmHg after standing is considered to be orthostatic hypotension. One of the most common causes of orthostatic hypotension is hypovolemia. The client likely will feel lightheaded and dizzy. This finding should be reported to the provider.

A nurse is providing teaching to a 17 year old female client who has severe acne about the use of isotretinoin. Which of the following adverse effects should the nurse instruct the client is the priority to report to the provider?

A school nurse is assessing a child for pediculosis capitis. Which of the following manifestations should the nurse recognize as an indication of this condition?

A nurse is caring for a child who has rheumatic fever. When obtaining the child's medical history from the parent, the nurse should recognize the significance of which of the following data as the possible source of the child's infection?

A sibling who had a sore throat 3 weeks ago; RF typically develops 2 to 6 weeks after an untreated or ineffectively treated streptococcal infection of the respiratory tract. If the sibling has a respiratory infection, it is likely the client also has a streptococcal respiratory infection.

What assessment finding in a newborn is suggestive of cystic fibrosis?

Abdominal distention; Meconium ileus is an indication that a newborn may have cystic fibrosis. The small intestine is blocked with thick, tenacious, mucilaginous meconium, usually near the ileocecal valve. This causes intestinal obstruction with abdominal distention, vomiting, and fluid and electrolyte imbalance. Rapid heart rate is not a sign of cystic fibrosis in the newborn. Excessive crying does not have special significance in cystic fibrosis. Sternal retractions are not a sign of cystic fibrosis in the newborn.

A nurse in an emergency department is caring for a child who is experiencing an acute asthma attack. Which of the following medications should the nurse expect to administer first? a. fluticasone b. budesonide c. montelukast d. albuterol

Albuterol

A nurse is preparing to measure an infant's vital signs. The nurse should use which of the following sites to assess a heart rate?

Apex of the heart; The most effective way to assess an infant's heart rate is to auscultate at the apex of the heart.

A home nurse is teaching a child's parents about endotracheal suctioning. Which of the following information should the nurse include in the teaching?

Apply suction for less than 10 seconds; Prolonged suctioning can cause damage to tissues and interfere with stages of respiration, cellular absorption, and blood transport.

A nurse in the pediatric clinic is assessing an 8-year-old child who has had asthma since infancy. What clinical finding requires immediate intervention?

Audible wheezing that is heard without a stethoscope is an indication that the airways are significantly compromised, and this requires immediate medical intervention. Barrel chest is a sign of chronic asthma. Repeated attacks result in a fixed hyper-aerated thoracic cavity; this clinical finding does not require intervention. A heart rate of 105 beats/min is expected in an 8 year old child, as is a respiratory rate of 30 breaths/min.

A nurse is caring for an 8 year old child who has acute rheumatic fever. Which of the following assessments is the nurse's priority immediately after admission?

Auscultating the rate and characteristics of the child's heart sounds; Using the ABC approach to client care, the nurse should place priority on auscultating the client's heart rate and heart sounds. Rheumatic fever is an inflammatory disease that begins with a strep throat from a streptococcal infection and can progress to rheumatic heart disease, which is a condition in which the heart values are damaged by rheumatic fever. Auscultating heart sounds is the priority assessment because tachycardia and cardiac murmur indicate cardiac involvement, which can result in serious, threatening, and life-long complications.

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?

Avoid a diet that consists primarily of milk; Milk is a poor source of iron and a diet that consists primarily of milk places the toddler at risk for iron deficiency anemia.