Peds ATI Practice Questions
A nurse is providing teaching about food high in fiber to the guardian of a child who has chronic constipation. Which of the following foods should the nurse recommend?
-1/2 cup cooked pinot beans rational: the nurse should recommend foods high in fiber for a child who has chronic constipation. A half cup of cooked pinto beans contain approx. 5 g of fiber. Therefore, the nurse should instruct the guardian to include this food in the child's diet
A nurse is caring for a child who ha tetralogy of Fallot. Which of the following lab values should the nurse expect to find?
-RBC 6.8 million/uL rational: a child who has tetralogy of Fallot experiences cyanosis; therefore, the body responds by increasing RBC production (polycythemia) in an attempt to supply O2 to all body parts
A nurse is providing immediate postoperative care for a preschooler who has a tonsillectomy. Which of the following actions should the nurse take?
-eliminate the use of a straw when offering fluids rational: straws can accidentally injure the surgical site and cause bleeding. their use should be avoided in the immediate postop period
A nurse is caring for an 8 yr old child who has acute glomerulonephritis. Which of the following findings should the nurse expect?
-periorbital edema rational: periorbital edema is an expected finding
A nurse in an emergency department is assessing a school-aged child who is experiencing an acute asthma exacerbation. Which of the following findings is the priority for the nurse to report to the provider?
-sudden decrease in wheezing rational: a sudden decrease in wheezing can indicate that the child is experiencing decreased air movement and should be reported; a sudden decrease in wheezing (silent chest) indicated ventilatory failure and imminent resp arrest
A nurse is preparing to assess a 3 month old infant during a well-child visit. Which of the following observations should the nurse expect?
-the infant looks at his hands rational: infants usually start to look at their hands while lying down or sitting between 12-20 wks of age. Convergence on near objects is usually well est. by 3 months of age
A nurse is reviewing recommended immunizations w/ the guardian of a 2 month old infant. Which of the following statements should the nurse make?
-your baby can start the pneumococcal vaccine now rational: the infant can receive the first dose of the pneumococcal vaccine now, with 2 additional doses at 4 months and 12 months of age
A nurse is teaching the parents of an infant who has congenital hypothyroidism. Which of the following directions should the nurse provide?
-your child will need to take thyroid hormone replacement for her entire life rational: in congenital hypothyroidism, the child does not manufacture an adequate amount of thyroid hormone to maintain the appropriate metabolic rate. The child will require lifelong thyroid hormone replacement to support normal growth and development
A nurse is performing an annual physical assessment of a preschooler. The parent expresses concern about the child's 1.8 kg (4lbs) weight gain over the past year. Which of the following responses should the nurse make?
-your child's weight change is expected for this age group rational: a preschooler should gain about 2-3 kg (4.4-6.6 lb) each yr. Therefore, the nurse should reassure the parent that this child's weight gain is an expected finding for the age group
A nurse is performing a nutritional screening for a 12 yr old client who weighs 41 kg (90 lbs) and has a height of 1.5 m (60 in). Which of the following values is the client's body mass index?
-18.2 rational: to calculate the client's BMI, the nurse should divide the client's weight in kilograms by the square of the client's height in meters. Therefore, 41 kg divides by the square of 1.5 m gives a correct BMI of 18.2
A nurse is assessing the pain level of a 3 yr old child who is postoperative following abdominal surgery. Which of the following pain scales should the nurse use?
-FACES pain rating scale rational: the FACES scale includes various faces, which represent various levels of pain. A 3 yr old child is able to ID faces that represent different pain levels
A nurse is providing discharge teachings for the parent of a newborn who is prescribed a Pavlik harness for developmental dysplasia of the hip. Which of the following responses indicates an understanding of the teaching?
-I should lightly massage my baby underneath the straps once a day rational: the parent should lightly massage the skin under the harness daily to promote circulation
A nurse is teaching the parent of an infant about injury prevention. Which of the following statements by the parent indicates an understanding of the teaching?
-I should make sure my baby's clothing does not have buttons rational: the nurse should instruct the parent to avoid clothing with buttons to reduce the risk of choking and aspiration
A nurse is teaching the parents of a 4 month old infant who has gastroesophageal reflux. Which of the following statements by a parent indicates an understanding of the teaching?
-I will add 1 teaspoon of rice cereal per oz to my baby's formula rational: the parents can give the infant thickened feedings with rice cereal to help decrease reflux. The added calories also can help infants who are underweight due to gastroesophageal reflux
A clinic nurse is providing teaching to the parent of a 1 month old infant who has gastroesophageal reflux. Which of the following statements by the parent indicates an understanding of the teaching?
-I will add rice cereal to my baby's feedings rational: the parent should add 1 tsp to 1 tbsp of rice cereal per ounce of formula or expressed breast milk to thicken the feedings and decrease the number of vomiting episodes
A nurse is teaching the parent of a toddler about home safety. Which of the following statements by the parent indicates an understanding of the teaching?
-I will lock my meds in the med cabinet rational: locking up meds and other poisons prevents access. toddlers have improves gross and fine motor skills that allow further exploration of the environment and possible access to hazardous substances
A nurse is teaching an adolescent who has asthma about how to use a peak expiratory flow meter. Which of the following responses by the adolescent indicates an understanding for the teaching?
-I will record the highest reading of three attempts rational: after est. a personal best, the client should routinely check the PEFM by performing 3 attempts and recording the highest reading of the 3
A nurse is providing teaching to a parent of a preschooler who has impetigo. Which of the following statements by the parent indicates an understanding of the teaching?
-I will wash my child's clothes in hot water rational: the parent should wash the child's clothes in hot water to kill bacteria. The parent should also keep the child's towels and washcloths separate from those of other members of the household
A nurse is admitting a child who has acute lymphocytic leukemia. Which of the following lab values should the nurse expect?
-RBCs 2.5 million/uL rational: an RBC count of 2.5 million/uL is below the expected reference range. A child who has acute lymphocytic leukemia has a low RBC count
A charge nurse is reviewing the expected growth and development of school-aged children with a group of staff nurses. Which of the following statements should the nurse include?
-a 6 yr old child should be able to count 13 coins rational: a 6 yr old child should be able to count 13 coins, ID morning and afternoon, and be able to ID right and left hands
A charge nurse on a pediatric unit receives the lab results for several clients. Which of the following results should the nurse report to the provider?
-a client who has diabetic ketoacidosis and a blood glucose of 375 mg/dL rational: the initial goal of therapy for DKA is a blood glucose level below 240 mg/dL. To accomplish this, the client should receive regular insulin via continuous IV infusion, and the nurse should monitor the blood glucose level hourly. The nurse should report this result so that the provider can adjust the client's insulin dosage
A nurse is planning care for an infant who has heart failure. Which of the following interventions should the nurse include in the plan to meet the nutritional needs of the infant? SATA
-allow 30 min to complete each feeding -gradually increase the caloric density of the formula -position the infant semi-upright during feedings -provide gavage feeding if respiratory rate exceeds 80/min rational: the nurse should allow 30 mins for each feeding. This length of feeding allows adequate intake w/out causing the infant to get overly fatigued or to lose needed rest time before the next feeding. The nurse should plan to provide the infant w/ a formula that has increased caloric density. An infant who has heart failure has an increased metabolic rate due to impaired cardiac function.
A nurse on a pediatric unit is planning care for a preschooler who will be having a surgical procedure in the morning. The child has been crying despite his parents' presence at his bedside. The nurse should add engaging the child in therapeutic play to the care plan to offer while of the following benefits?
-allow the child to manipulate toy medical equipment rational: a major function of play therapy is making potentially unmanageable situations manageable through symbolic representation, which provides kids w/ opportunities to learn to cope. A preschooler does not have the language development to express fear of the unfamiliar medical equipment in the hospital. By encouraging th child to touch the equipment, the nurse is helping decrease the child's fear and intimidation in a safe environment using age-appropriate vocabulary. The use of toys enables kids to transfer anxieties, fears, fantasies, and guild to objects rather than people
A nurse is caring for a 4 month old child who has acute otitis media and a fever of 38.3 C (101 F). Which of the following meds should the nurse administer?
-amoxicillin rational: a child who has acute otitis media should take an antibiotic to help alleviate the infection
A nurse is caring for a child who has a possible intussusception. The parents of the child ask the nurse how the diagnosis is determined. Which of the following responses should the nurse make?
-an abdominal ultrasound will confirm the pocket in the intestine rational: intussusception is the invasion of a part of the intestine into another, creating a pocket. The presence of an intussusception is confirmed by an abdominal x-ray, ultrasound, or CT scan
A nurse is caring for a school-aged child who has hemophilia and fell on the playground. The child reports a pain level of 4 on a scale of 0-10. Which of the following actions should the nurse take?
-apply an ice pack to the joint rational: immediately following an injury, a joint should be rested, elevated, and have ice applied to minimize bleeding into the joint
A nurse is caring for a child who has epistaxis. Which of the following actions should the nurse perform?
-apply continuous pressure to the child's nose for at least 10 min rational: the nurse needs to apply continuous pressure for at least 10 mins to help stop bleeding
A school nurse is providing care to a child who has a nosebleed. Which of the following actions should the nurse perform? SATA
-apply pressure to the child's nose using the thumb and forefinger -keep the child calm rational: applying pressure continuously for 10 mins to the nose w/ the thumb and forefinger helps control the bleeding. Most bleeding comes from the front portion of the nasal septum, so pressure on this area is generally effective. If bleeding persists, placing ice or a cold cloth on the bridge of the nose and inserting cotton or tissue into the nostril might help. The nurse should keep the child calm to help slow the bleeding. Agitation can raise blood pressure, which will increase the bleeding
A nurse is admitting a child who has a UTI and a history of myelomeningocele. After completed the admission history, which of the following actions should the nurse plan to take?
-attach a latex allergy alert ID band rational: myelomeningocele, a serious complication of spina bifida, is a neural tube defect in which the spinal cord and meninges are in a cerebrospinal fluid filled sac at birth. clients who have neural tube defects are at risk of latex allergy; therefore, the nurse should avoid the use of common medical products containing latex such as gloves
A nurse is providing education about the introduction of solid foods for the parent of an infant. Which of the following instructions should the nurse include?
-begin after the extrusion reflex has diminished rational: the nurse should explain that the extrusion reflex results in food being pushed out of the mouth instead of being swallowed. the tongue extrusion reflex diminishes after 4 months of age
A nurse is caring for a 2 yr old child who has cystic fibrosis. The nurse is planning to take the child to the playroom. Which of the following activities would be appropriate for the child?
-building towers w/ blocks rational: building towers w/ blocks is an appropriate activity for a 2 yr old child and promotes fine motor development. Also, knocking blocks down provides a means of dealing w/ the stress of hospitalization
A nurse is assessing a toddler who has AIDS. Which of the following findings is an indication of an opportunistic infection?
-candidiasis rational: candidiasis (oral thrush) results from the overgrowth of Candida albicans, an opportunistic fungus that commonly infects the oral cavity of clients who have immature or compromised immune systems. Candidiasis appears as a cheesy, white plaque that looks like milk curds on the buccal mucosa and tongue. Thrush is often the initial opportunistic infection in an HIV-positive child who is developing AIDS
A nurse is assessing an infant who has acute gastroenteritis. Which of the following findings should the nurse ID as the priority?
-capillary refill 5 seconds rational: when using the urgent vs nonurgent approach to client care, the nurse should ID that the priority finding is a cap refill of 5 seconds. A cap refill about 4 sec is an indication of severe dehydration and requires immediate intervention to prevent progression to hypovolemic should
A nurse in the emergency department is caring for a 2 yr old child who was found by his parents crying and holding a container of toilet bowl cleaner. This child's lips are edematous and inflamed, and he is drooling. Which of the following is the priority action by the nurse?
-check the childs resp status rational: ABC's; this child's lips are edematous and inflamed, and he is drooling these findings indicate that the child might have swelling of the oral cavity and pharynx, which can result in a compromised airway
A nurse is assessing a child who is postop and received a unit of packed RBCs during a surgical procedure. Which of the following findings indicates the child is experiencing a hemolytic transfusion reaction?
-chills and flank pain rational: chills and flank pain indicate an incompatibility of the transfused blood product w/ the client's blood. The nurse should ID that the child is having hemolytic reaction
A nurse is caring for a 3 yr old child on a peds unit. The nurse should ID which of the following an an appropriate toy for the child?
-coloring book & crayons rational: preschoolers have increasing fine motor control and imagination. they enjoy toys that allow creativity and self expression
A nurse is assessing the fine motor skill development of a 4 yr old child. The nurse should expect the child to be able to perform which of the following activities?
-copying a square rational: the nurse should expect a 3 yr old child to have the fine motor ability to copy a circle. A 4 yr old child should have the ability to copy a square
A nurse is assessing the vital signs of a 1 month old infant. Which of the following actions should the nurse perform?
-count respirations before taking other vitals signs rational: it is best to count the infant's respirations while the infant is calm and before being disturbed. the pulse should be taken next, followed by the temp, which is the most disruptive assessment to an infant
A nurse is teaching the guardian of a school-age child who has diabetes mellitus how to recognize diabetic ketoacidosis. Which of the following findings should the nurse identify as a manifestation of this complication?
-deep rapid respirations (Kussmaul) rational: deep and rapid resp. are known as kussmaul resps. which is a manifestation of DKA. this resp pattern is caused by the body's attempt to rid itself of the excess carbon dioxide that results from the presence of ketones. This child's breath can be sweet smelling due to body's attempt to eliminate ketones through the resp system
A nurse is assessing a toddler who has gastroenteritis. Which of the following findings indicates the toddler is experiencing severe dehydration?
-deep, rapid respirations rational: this finding is a manifestation of severe dehydration. other manifestations include weight loss of 10% or more, parched mucus membranes, and tachycardia
A nurse is assessing a 4 yr old child's cognitive development during a well-child visit. Which of the following should the nurse expect the child to display?
-development of the superego rational: this is the development of a conscience. Preschoolers begin to develop an understanding of right from wrong. While they might be unable to understand the "why" of acceptable vs unacceptable behaviors, they learn the concept through punishment and reward and the principles to which their parents adhere
A nurse at a clinic is preparing to administer immunizations to a 5 yr old child. Which of the following immunizations should the nurse plan to give?
-diphtheria, tetanus, and pertussis (DTaP) rational: kids should receive booster doses of the DTaP immunizations between the ages of 4 and 6. around this age, blood titers drop due to decreasing antibodies
A nurse is caring for a school aged child who begins to have a tonic-clonic seizure when leaving the bathroom. Which of the following actions should the nurse take first?
-ease the child to the floor in Sims' position rational: the greatest risk to the child is an injury resulting from a fall; therefore, the nurse should first gently ease the child to the floor to decrease the chance of injury and turn the child on the left side to prevent aspiration
A nurse is planning to use guided imagery for an early school-aged child who continues to have mild discomfort following the administration of an analgesic. Which of the following techniques should the nurse plan to use?
-encourage the child to focus on a recent pleasurable experience rational: the nurse should encourage the child to focus on a recent pleasurable experience such as a trip to the zoo, when using the nonpharmacological technique of guided imagery. This technique encourages the child to focus on the pleasurable experience rather than the sensation of pain. This technique can also be combined w/ relaxation and breathing techniques
A nurse is planning care for a school-aged child who has juvenile idiopathic arthritis. Which of the following actions should the nurse include in the plan?
-encourage the child to participate in physical activities rational: the nurse should encourage the child to remain physically active to promote mobility and joint function
A nurse is teaching the guardian of an 18 month old toddler about otic medication administration. Which of the following statements should the nurse make?
-gently pull the ear cartilage down and back when administering the medication rational: the nurse should instruct the guardian to pull the pinna gently down and back to straighten the eustachian tube when administering the medication
A nurse is performing a visual acuity screening for a school-aged child using the Snellen letter chart. Which of the following actions should the nurse take?
-have the child wear his glasses during the vision screening rational: the nurse should assess the child's acuity while the child is wearing prescribed glasses
A nurse is assessing a 12 month old male infant's vital signs during a well child visit. The infant is in the 90th percentile for height. Which of the following findings should the nurse report to the provider?
-heart rate 175/min rational: a HR of 175 is above the expected reference range for a 12 month old; therefore, the nurse should report
A nurse is caring for a 16 yr old client who reports dysmenorrhea and asks about alternative therapies for treatment. Which of the following statements should the nurse make?
-herbal meds can be effective but should be monitored by your provider rational: herbal meds may be helpful in relieving menstural pain. However, there is a risk of toxicity and drug interactions if herbal med is taken in the wrong doses or w/ other meds. the nurse should ask the client if she is using herbal med and document the does and effects
A nurse is developing a health education program for the parents of school-aged females. Which of the following pieces of information regarding sexual maturation should the nurse include?
-higher body fat content is associated w/ earlier onset of menarche rational: the nurse should inform the parents that the onset of menarche is expected to occur around 10.5-15.5 yrs of age. Females who have a higher body fat content have been shown to have an earlier onset of menarche
A nurse is providing teaching for a parent about pinworm testing. At which of the following times should the nurse advise the parent to perform the tape test?
-immediately after the child wakes up in the morning rational: the nurse should instruct the parent to perform the tape test as soon as the child wakes up in the morning and before the child bathes or uses the restroom. The test should be repeated for 3 mornings in a row
A nurse is caring for a 4 yr old child who has pneumonia. The child's mother left 2 hrs ago, and he is currently experiencing the separation anxiety stage of despair. Which of the following findings should the nurse expect?
-inactivity and thumb sucking rational: a child who is sucking his thumb and refusing to eat or drink is displaying manifestations of the second state of separations anxiety, which is despair
A nurse is providing discharge teaching to the parents of a child who has nephrotic syndrome. Which of the following instructions should the nurse include in the teaching?
-keep the child away from people who have an infection rational: children who have nephrotic syndrome are at increased risk for infection and should avoid contact w/ people who have infections
A nurse is assessing an adolescent who has a new diagnosis of anorexia nervosa. Which of the following findings should the nurse expect?
-lanugo over the back rational: the nurse should expect an adolescent who has anorexia nervosa to have lanugo present on the skin as a result of impaired metabolic activity. Other manifestations of anorexia nervosa include hypothermia, hypotension, and dry skin
A nurse is providing teaching to a parent of a preschooler who has tinea capitis. Which of the following instructions should the nurse include in the teaching?
-leave the medicated shampoo on the scalp for 5-10 mins rational: the nurse should instruct the parent to use a shampoo made of 2% ketoconazole or 1% selenium sulfide for the treatment of tinea capitis. For the shampoo to be effective, the parent should leave it on the child's scalp for 5-10 mins prior to rinsing
A nurse is planning care for an adolescent who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions should the nurse include in the plan?
-maintain the child on bed rest rational: the nurse should maintain bed rest for this child who is experiencing a vaso-occlusive crisis to minimize energy expenditure and avoid additional O2 needs
A nurse is caring for an infant who is postop following a myelomeningocele repair. Which of the following is the priority action the nurse should take?
-measure the infants head circumference rational: increased head circumference is an indication that the infant is at greater risk of increased intracranial pressure; measuring the infant's head circumference is the priority nursing action. Hydrocephalus can occur as a complication of a myelomeningocele repair and is monitored using head circum. measurements.
A nurse is creating a plan of care for a child who has leukopenia secondary to chemotherapy. Which of the following interventions should the nurse include in the plan?
-monitor the child for increased temp rational: leukopenia places the child at risk of infection; therefore, the nurse should monitor the child for a fever
A nurse is creating a plan of care for a child who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions is the priority for the nurse to include?
-monitor the child's O2 sat rational: when using the ABC approach to client care, the priority intervention is to monitor the child's O2 sat level. Promoting O2 utilization prevents further sickling of the child's RBCs and allows adequate oxygenation of the surrounding tissue
A nurse is caring for a 2 day old infant who has myelomeningocele. Which of the following actions should the nurse take?
-monitor the infant's head circumference rational: infants with myelomeningocele have an increased risk of hydrocephalus. Measuring the infant's head circumference helps determine any increase of fluid
A nurse is assessing a 6 month old infant. The guardian reports that the infant does not appear interested in the brightly colored mobile hanging above the crib at home. Which of the following techniques should the nurse use to check the infant's visual acuity?
-move a brightly colored toy from side to side in front of the infant's face rational: the nurse should check the infant's ability to see by positioning the infant upright and holding a brightly colored toy or object in front of the infant's face and moving it from side to side. The nurse should observe the infant's ability to fixate on the toy and track its movement. The nurse can also perform this assessment using the human face as a visual target
A nurse is teaching the parents of a child who has rheumatic fever. Which of the following statements by a parent indicates an understanding of the teaching?
-my child may take aspirin for his joint pain rational: kids who has rheumatic fever may take salicylates (aspirin) to control the inflammatory process that occurs in the joints
A nurse is providing teaching to the parent of a 2 yr old toddler about nutrition? Which of the following statements by the parent indicates an understanding of the teaching?
-my child should consume 1,000 cal per day rational: toddlers who are 2 yrs old should consume 1000 cal daily
A nurse is performing a neurological exam on a 15 month old toddler. Which of the following findings should the nurse expect?
-negative Babinski reflex rational: the nurse should expect a negative Babinski reflex from a 15 month old toddler because this reflex usually disappears around 12 months of age
A nurse is planning care for a toddler who has acute gastroenteritis and was recently admitted. Which of the following should the nurse plan to provide for the child?
-oral rehydration solution rational: the nurse should plan to provide an oral rehydration solution to this child who has acute gastroenteritis. ORS promotes the body's reabsorption of water and sodium and is more effective and less traumatic than the administration of IV fluids for the tx of dehydrations due to diarrhea and emesis
A nurse is teaching the parent of an infant about home safety. Which of the following pieces of info should the nurse include? SATA
-position the care seat so it is rear facing -secure a safety gate at the top and bottom of the stairs -maintain the water heater temp at 49 C (120F) rational: infants and kids should remain in the rear facing position in a care seat until the age of 2 yrs or until they reach the recommended height and weight per the manufacturer's guidelines. As the infant begins to crawl and becomes more mobile, the risk of falls increase. To prevent burn injury, the temp of the water heart should not exceed 49 C ( 120F)
A nurse is caring for an infant who has a tracheoesophageal fistula. Which of the following actions should the nurse take?
-preform oropharyngeal suctioning rational: when caring for an infant who has a tracheoesophageal fistula, the nurse should perform frequent oropharyngeal suctioning to decrease the infant's risk of aspiration
During a well-child visit, the guardian of a toddler reports that the toddler takes several hours to fall asleep at night. Which of the following recommendations should the nurse make?
-provide the toddler w/ a favorite stuffed animal at bedtime rational: providing the toddler w/ a fav soft toy at bedtime can help the toddler feel more secure and facilitate sleep
A nurse is planning care for a 4 yr old child who has nephrotic syndrome. Which of the following actions should the nurse take?
-provide thorough skin care rational: the nurse should provide thorough skin care for this child who has nephrotic syndrome. Skin care is especially important due to edema and the risk of infection
A nurse is discussing play activities w/ a group of parents of toddlers. Which of the following activities should the nurse recommend for this age group?
-pushing a toy lawn mower rational: the nurse should recommend pushing a toy lawn mower as a play activity for a toddler. Toddlers are developmentally ready for push-pull toys, and they enjoy play activities that allow imitation of adults
A nurse is admitting a child who has Wilms' tumor. Which of the following actions should the nurse take?
-put a "no abd palpation" sign over the child's bed rational: the nurse should place a sign over the child's bed stating "no ABD palpation" because palpation is not necessary to confirm diagnosis and could prompt metastasis
A nurse is creating a plan of care for a preschooler who was admitted for the treatment of measles. Which of the following activities should the nurse include in the client's care plan?
-putting together a puzzle with larger pieces rational: the nurse should recommend putting together a puzzle with large pieces for a hospitalized preschool. other recommended activities preschooler on airborne precautions include playing pretend and dress up, painting, and looking at illustrated books
A nurse is talking with the parent of an infant during a well-child visit. The parent states, "My 6 yr old child started wetting the bed after we brought her baby sister home. She hasn't done that in over a year." This behavior by the sibling is an indication of which of the following defense mechanisms?
-regression rational: the nurse should ID that the 6 yr old sibling's behavior is an indication of regression. W/ this defense mechanism, the individual reverts to a prior stage of development as a means of coping w/ stress
A nurse is providing teaching about home safety to the parent of a 2 month old infant. Which of the following info should the nurse include?
-remove bibs before the infant goes to sleep rational: the nurse should instruct the parent to remove bibs prior to the infant sleeping to decrease the risk of strangulation
A nurse i8s caring for a child who has a tracheostomy. Which of the following techniques should the nurse use to suction the child's tracheostomy?
-remove the catheter while applying intermittent suction rational: the nurse should insert the catheter w/out suction & then withdraw the catheter while applying intermittent suction
A nurse is providing nutritional teaching to an adolescent client who has celiac disease. Which of the following breakfast foods should the nurse recommend?
-scrambled eggs rational: a client who has celiac disease should be on a gluten-free diet and should avoid foods containing barley, oat, rye and wheat; therefore, scrambled eggs are an appropriate breakfast item for the nurse to recommend to the client
A nurse is reviewing the lab values for a 6 month old infant who has acute renal failure. Which of the following findings should the nurse expect?
-sodium 125 mEq/L rational: the nurse should expect an infant w/ acute renal failure to have hyponatremia. a sodium level of 125 is below the expected reference range
A nurse is assessing a 4 yr old child for growth and developmental milestones during a well child visit. Which of the following findings suggests a possible delay in development?
-speaking using 2-3 sentences rational: a 4 yr old child should be speaking in 4-5 word sentences. Speaking in 2-3 word sentences is typical of a 2 yr old child
A nurse is caring for an 18 month old infant who has chronic otitis media. The nurse should recognize that chronic otitis media will affect which of the following?
-speech patterns rational: chronic otitis media can result in hearing loss, which can affect speech development
A nurse in an acute pediatric unit is caring for a 2 yr old child who has separation anxiety when her parents to leave for work. The nurse should ID which of the following behaviors as a manifestation of the stage of despair?
-the child attempts to run away to find her parents rational: separation anxiety manifests in 3 stages: protest, despair, and detachment. Withdrawal and lack of communication are manifestations of the stage of despair
A nurse is performing a well-child assessment on a 4 yr old child. Which of the following findings should the nurse expect?
-the child is able to hop on 1 foot rational: the nurse should expect a 4 yr old child to have the gross motor ability to hop on 1 foot
A nurse is preparing to assess a 2 yr old toddler. Which of the following behaviors should the nurse expect during the exam?
-the child prefers to sit on the parent's lap during the exam rational: toddlers and infants who are able to sit typically prefer to sit in their parents' lap throughout the exam
A nurse is caring for a school-aged child who has an arm cast applied 8 hrs ago. Which of the following findings should alert the nurse to a complication related to the casting?
-the child reports tightness at the wrist rational: the nurse should monitor the casted extremity to ensure the swelling does not increase and cause the cast to become too right, which can result in impaired circulation. if this occurs the child is at risk for compartment syndrome
A nurse is caring for a preschool-age child who is dying. Which of the following findings is an age-appropriate reaction to death by the child? SATA
-the child views death as similar to sleep -the child believes his thoughts can cause death -the child thinks death is a punishment rational: preschool-age child may think of death like sleep. Preschool-age kids also believe that their thoughts and wishes can make things happen since they are egocentric. This is part of why the death of a family member can be difficult for a child at this age. Finally, preschool-age kids sometimes believe that death is the result of guild or a punishment for something they did, said, or thought
A nurse is discussing disciplinary techniques with the guardian of a preschooler. Which of the following actions indicates to the nurse that the guardian is using an age-appropriate disciplinary technique?
-the guardian places the child in time-out after misbehaving rational: the nurse should encourage the guardian to continue to use time-out as a form of discipline. This technique is effective w/ a preschooler if carried out correctly. The nurse should review the process of using time-outs w/ the guardian (ensuring the time-out takes place in a safe and quiet location) and recommend that the length of time-out is 1 min for each year of the child's age
A nurse is reviewing the medical record of a 2 month old infant who has rotavirus. The nurse notes a hemoglobin level of 12 g/dL and hematocrit of 51%. Which of the following statements by the nurse indicates an understanding of the lab values?
-the infant might be dehydrated rational: an increased hematocrit level indicates dehydration. Hematocrit levels rise when blood volume is decreased during dehydration
A nurse is a provider's office enters an exam room to assess an 8 month old infant for the first time. Which of the following reactions by the infant should the nurse expect?
-the infant turns away when the nurse approaches rational: the nurse should expect an 8 month old infant to have a heightened fear of strangers. the infant is expected to cling to her parent and turn away when approached by a stranger
A nurse is assessing a 6 month old infant at a well child visit. Which of the following findings indicates the need for further assessment?
-the infant's legs remain crossed & extended when supine rational: legs that are crossed and extended when supine is an unexpected finding and requires further assessment. At 6 months of age, the infant's legs flex at the knees when the infant is supine. Crossed and extended legs when supine is associated w/ cerebral palsy
A nurse is providing teaching about immunizations to the parents of a severely immunocompromised child who has HIV. Which of the following statements should the nurse include in the teaching?
-the pneumococcal and influenza vaccines are recommended for your child rational: immunization against common childhood illnesses, including influenza and pneumococcal disease, is recommended for all children exposed to and infected w/ HIV
A nurse is assessing the fine motor skills of a 3 yr old preschooler. Which of the following findings should the nurse expect?
-the preschooler builds a tower of 9 cubes rational: the nurse should expect a 3 yr old preschooler to have the fine motor skills needed to build a tower a 9-10 blocks
A nurse is preparing to obtain an antistreptolysin O (ASO) titer form a child who has acute glomerulonephritis. The child's parent asks the nurse to explain the purpose of the test. Which of the following response should the nurse provide?
-the test shows us if your child had a recent strep infection rational: an ASO titer indicates the child has a recent strep infection. when determining a definitive diagnosis for acute glomerulonephritis, this must be documented because the condition is usually the result of this type of infection
A nurse is providing teaching to the guardian of a 9 month old infant who has a new prescription for an oral liquid medication. Which of the following points should the nurse include in the teaching?
-use an oral syringe to measure your infant's medicine accurately rational: an oral syringe is the best method for accurately measuring small amounts of liquid meds. Additionally, the syringe allows the caregiver to deposit small amounts of the med along the side of the infant's tongue to decrease the risk of aspiration
A nurse in the ER is assessing an infant who recently started taking digoxin to treat a supraventricular arrhythmia. Which of the following findings should the nurse ID as an indication of digoxin toxicity?
-vomiting rational: the nurse should ID that vomiting, especially when unrelated to feedings, is a manifestation of digoxin toxicity. The nurse should report this finding to the provider immediately
A nurse is providing teaching to the family of a child who has autism spectrum disorder. Which of the following statements indications that the family understands the teaching?
-we can help our child by structuring our daily routine rational: kids who has autism spectrum disorder benefit from the structured routine. this environment can minimize the anxiety the child might have w/ sudden schedule changes and socialization requirements and satisfy a preference for ritualistic behavior
A nurse is teaching the parents of a 3 yr old child who has persistent otitis media about prevention. Which of the following statements by the parents indicates an understanding of the teaching?
-we should not smoke around our child rational: preventing exposure to tobacco smoke at home can prevent further episodes of ear infections because tobacco smoke can cause inflammation of resp tract
A nurse is caring for a 15 month old child who requires droplet precautions. Which of the following actions should the nurse take?
-wear a mask when assisting the toddler w/ meals rational: the nurse should wear a mask w/in 3-6 feet of the toddler to prevent the transmission of infections that are spread via large-droplet particles expelled in the air
A nurse is caring for a child who has glomerulonephritis. Which of the following actions should the nurse take?
-weigh the child once each day rational: the nurse should weigh the child at the same time each day to monitor fluid balance
A nurse is caring for an infant who has biliary atresia. Which of the following manifestations should the nurse expect? SATA
-yellow sclerae -abd distention -dark urine rational: biliary atresia is a progressive process that leads to the destruction of the biliary tree. Yellow sclerae are an early manifestation of biliary atresia caused by obstruction of the biliary tree, resulting in cholestasis. ABD distension is a clinical manifestation of biliary atresia due to hepatomegaly. Dark urine due to conjugated bilirubin escaping from the liver and being excreted in the urine
A nurse is providing teaching to a 12 yr old client who is recovering from an acute episode of hemophilia A. Which of the following statements should the nurse include in the teaching?
-you will be able to participate in physical exercises rational: physical exercise is important for the maintenance of joint mobility and muscle strengthening. participation in non-contact sports and the use of protective equipment such as knee pads are encouraged, although high-impact athletic activities such as karate should be avoided
A nurse is providing teaching about disease-management strategies to a 9 yr old client who has cystic fibrosis. Which of the following statements should the nurse include?
-your mucus is thick because cystic fibrosis interferes w/ how your glands work rational: a 9 yr old child should understand that the production of thick mucus is part of the disease process
