Peds Hesi
An adolescents mother calls the primary healthcare provider office to inquire the results of her daughter's serum test results that were drawn last week Since it is the teenager's 18th birthday, how should the nurse respond to the mother's inquiry?
Explain that the information cannot be released without the 18 years old permission
A 9-year-old with leukemia is admitted with a ruptured appendix. A nasogastric tube is inserted and attached to low intermittent suction. Which finding is most important for the nurse to report to the healthcare provider? A. Increased BUN B. Urinary output of 60 ml/hour C. Gastric output of 450 ml in last 24 hours D. Absolute neutrophil count of 400/mm3
D. Absolute neutrophil count of 400/mm3
A school age child newly diagnosed with celiac disease is ordering food tray which foods should the nurse list as acceptable options for the child's diet? (select all that apply) A. Milk B. Mashed potatoes. C. Gravy. D. Chicken. E. Wheat bread. F. Corn.
A. Milk B. Mashed potatoes. D. Chicken F. Corn.
A nurse is caring for adolescent with a BMI above the 95th percentile who has been experiencing increased urination which diagnostic test should the nurse anticipate? A. Kidney ureters and bladder.(KUB) x ray B. Blood sodium level. C. Urine human chorionic gonadotropin (hCG) D. Serum hemoglobin A1C
D. Serum hemoglobin A1C
The nurse administer digoxin to a 9 month old infant with an apical heart rate of 160 beats per minute. Which indicates the medication effect has been achieved. 60 beats per minute 120 beats per minute 180 beats per minute 80 beats per minute
120 beats per minute
The nurse is caring for a child with sickle cell disease who is experiencing a sickle cell crisis. Which finding should the nurse report to the healthcare provider immediately? A. Swelling in the hands or feet B. Jaundice C. Ulcers on the legs D. Chest pain
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A preschool-age child in experiencing respiratory distress is brought to the emergency department by the parents. The child is anxious, has a temperature of 102.8 F (39.3C), and is drooling from the mouth while leaning forward when sitting. Which action should the nurse prepare the child next? A Obtain bedside trays for intubation or tracheotomy by the healthcare provider B Begin prescribed intravenous antibiotic administration C Provide a nebulizer treatment with bronchodilators D Schedule the child for a stat magnetic resonance imaging (MRI) of the neck
A Obtain bedside trays for intubation or tracheotomy by the healthcare provider
A 3 month old with meningococcal and atonic bladder is catheterized every four hours to prevent urinary retention. The home health nurse notes that the child has developed episodes of sneezing, urticaria , watery eyes and a rash in the diaper area. What action is most important for the nurse to take? A. Change to latex free gloves when handling infant. B. Auscultate the lungs for respiratory pneumonia. C. Apply zinc oxide to perineum with each diaper change. D. Draw blood to analyze for streptococcal infection.
A. Change to latex free gloves when handling infant.
An adolescent with pelvic inflammatory disease is admitted to the hospital after 14 days of taking Lovafioxacin 500mg orally once daily and matroidazole 500mg twice daily she asks the nurse "why do I have to be in the hospital? Why can't I get my treatment at home" which purpose should the nurse provide of for an effective outcome?
Administration of a supervised parenteral antibiotic protocol
A nurse is teaching a class for mothers of premature infants and is asked about " a shot for respiratory virus." What information about palivizumab is correct? A. It must be repeated every two months to be effective B. It is recommended for infants who meet established high-risk criteria C. It is a required immunization for all infants under the age of 3 months D. It provides protection one year with a single injection
B. It is recommended for infants who meet established high-risk criteria
A infant recently admitted with vomiting and diarrhea now weighs 10kg. Her weight at previous visit was 11kg. What is the percentage of baby weight loss for this infant? A 4% B 9% C 10% D 5%
B 9%
The caregiver of a preschooler learns about long-term endocrine dysfunctions resulting from their child's craniospinal radiation. Which statement made by the caregiver should the nurse recognize as needing additional education? A. Follow up at a dentist routinely to monitor for delayed tooth eruption B. Make plans for growth hormone injections to enhance growth C. Onset of cold intolerance and dry skin may indicate a problem D. Development of secondary sex characteristics may be slower
B) make plans for growth hormone injections to enhance growth
A 9-year-old with celiac disease is admitted to the pediatric unit following an appendectomy. Which food should the nurse remove from this child's meal tray? A. Fruit cup B. Crackers C. Turkey D. Chicken rice soup
B. Crackers
A hospitalized child stiffens and starts to seize as the nurse enters the room. What actions should the nurse take? Select all that apply. A. Instruct the parents to leave the room. B. Pad side rails with available pillows and blankets. C. Notify the emergency response team. D. Monitor duration and progress of the seizure. E. Turn client to the side if possible
B. Pad side rails with available pillows and blankets. D. Monitor duration and progress o the seizure E. Turn client to the side if possible
The nurse is teaching a group of adolescents about the risk factors of hepatitis. Which risk factor is most important to the nurse to include on the teaching plan? A. Family lifestyle. B. Unprotected sexual intercourse. C. Peer pressure. D. Pubescences
B. Unprotected sexual intercourse.
A mother brings her 2-month-old son to the clinic for a well-baby exam. During the assessment the nurse finds that the right testicle in not descended into the scrotum, but the left is palpable. Which action should the nurse take? A. prepare to obtain a catheterized urine specimen for culture B address possible concerns about the child's future fertility C Ask if the right testis has been seen in the scrotum before D Schedule an IV pyelogram to validate presence of testicle
C Ask if the right testis has been seen in the scrotum before
A 4-year-old girl returns to the pediatrician's office for a postoperative visit following hospitalization for minor surgery. When observing the child in the waiting area, which behavior should the nurse consider normal for this age child? A. Ignores other children in the play area B. Draws pictures of self with facial features C. "Talks" to an imaginary friend D. Sits quietly in her mother's lap
C. "Talks" to an imaginary friend
The nurse is planning care for a newborn infant scheduled for a cardiac catheterization. Which occurrence poses the greatest risk for this child? A. Loss of pulses proximal to the entry site of the cardiac catheter B. Allergic response to the plastics in the catheter used for catheterization. C. Acute hermorrhage from the entry site of the catheter after the procedure D. Fever associated with nausea and vomiting after the procedure.
C. Acute hermorrhage from the entry site of the catheter after the procedure.
The mother of a 14-month-old tells the nurse that she feeds her child nothing but prepared toddler foods and feels they provide the best nutrition for her child but is concerned about the cost. How should the nurse respond? A. Teach the mother how to develop a budget to allow her to continue to provide needed prepared toddler foods. B. Advise the mother that these foods will only be needed until the growth spurt of the toddlers' years to complete C. Reassure the mother that beginning to replace prepared foods with table foods can provide the needed nutrients D. Affirm that these prepared foods are the best way to ensure that the toddler gets all the needed nutrients
C. Reassure the mother that beginning to replace prepared foods with table foods can provide the needed nutrients
The nurse is administering a nebulized albuterol treatment to a young girl who is having an asthmatic exacerbation. The client is unable to hold her lips tightly around the mouthpiece. Which intervention should the nurse implement? A. Encourage the child to keep a tight seal B. Allow the treatment to blow in the face C. Replace the mouthpiece with a mask D. Decrease the nebulizer air flow rate
C. Replace the mouthpiece with a mask
Parents bring the 8 month old daughter to the clinic because they are concerned that she is not developing asked her older brother did. which developmental characteristic should the nurse expect an eight month old to exhibit? A. Pulls self to sitting position. B. Can feed finger food. C. Sits alone unsupported. D. Takes a first step alone
C. Sits alone unsupported.
A breastfeeding infant, screened for congenital hypothyroidism is found to have low levels of thyroxine (T4) and high levels of TSH. What is the best explanation for this finding? A. The thyroid gland does not produce normal levels of thyroxine for several weeks after birth B. The Thyroxine level is low because the TSH level is high C. The TSH is high because the low production of T4 by the thyroid D. High Thyroxine levels normally occur in breastfeeding infants
C. The TSH is high because the low production of T4 by the thyroid
The nurse is assessing a 6-month-old infant. Which response required further evaluation by the nurse? A Has double birth weight B Turns head to locate sound C Plays "peek-a-boo" D Demonstrates startle reflex
D Demonstrates startle reflex
The nurse is communicating with a 12-year-old who is hearing impaired. Which action is best for the nurse to use when attempting to communicate with this child? A. Use a picture boarded to communicate needs B. Convey ideas by writing short sentences C. Attract the child's attention before speaking D Emphasize emotions with facial expressions
D Emphasize emotions with facial expressions
The parents of a 3-year-old boy who has Duchenne muscular dystrophy (DMD) asks, " How can our son have this disease? We are wondering if we should have any more children." Which information should the nurse provide to these parents? A. The striated muscle group of males can be impacted by a lack of the protein dystrophin in their mothers B. Birth trauma with a breech vaginal birth causes damage to the spinal cord, thus weakening the muscles C. The male infant had a viral infection that went unnoticed and untreated, so muscle damage was incurred D. This is an inherited X- Linked recessive disorder, which primarily affects male children in the family
D. This is an inherited X- Linked recessive disorder, which primarily affects male children in the family
The nurse is caring for a school age- child who has ;laboratory results that reveal the presence of anti-endomysial immunoglobulin G and immunoglobulin A antibodies. The nurse should identify with the parents and child which foods to avoid after discharge to home? A. Swiss cheese B. Sweet potatoes C Orange juice D. Wheat bread
D. Wheat bread
A 12-year-old child is admitted to the hospital with possible encephalitis and a lumbar puncture is scheduled. Which information should the nurse provide this child concerning the procedure?
Describe the side-lying knees to the chest position that must be assumed during the procedure.
In assessing a 17-year-old newly diagnosed with osteomyelitis which information is most important for the nurse to obtain?
Family history of bone disorders.
Which nutritional information should the nurse plan to provide the mother of a six month old regarding introduction of solid foods?
Food should be introduced into child's diet one at a time at 4 to 7 day intervals.
The nurses are assessing a toddler who was admitted it was suspected and intussusception and presence with vomiting, lethargic, and blood and mucus present in the stool. which action should the nurse implement first ?
Maintain NPO status in initiate IV fluid hydration.
Several children at a day camp return from playing in a tick infested field which action should the nurse take first?
Observe the children skin for attach ticks
The pediatric unit is extremely busy when the admission office notifies the charge nurse that a child who has acute lymphocytic leukemia(ALL) needs to be admitted to the unit. The parents brought prescriptions from the healthcare provider for the child to have a chest, x-ray and blood work drawn on admission what action should the charge nurse take?
Tell the admission clerk to bring the child immediately to the unit and place a child in a private room.
A 6-year-old child is diagnosed with rheumatic fever and demonstrates associated chorea (sudden aimless movements of the arms and legs). Which information should the nurse provide to the parents?
The chorea or movements are temporary and will eventually disappear
The nurse is administering an oral medication to a reluctant preschool-aged boy. which intervention should the nurse implement?
Use straightforward approach with the child
A mother brings her preteen daughter to the clinic for her first female examination. During the health assessment, the nurse should implement which technique to determine if the client has reached menarche? A. Calculate approximate age menstruation should occur B. Palpate for evidence of temporary gynecomastia C. Assess for presence of a supernumerary breast nipple D. Use the Tanner staging to determine sexual maturity
Use the Tanner staging to determine sexual maturity
The nurse is assessing a 9-year-old boy who has been admitted to the hospital with possible acute poststreptococcal glomerulonephritis (APSGN). In obtaining his history, what information is most significant. A. A sore throat B. A history of hypertension c. Diuresis during the night d. Back pain for a few days
A. A sore throat
A 7-year-old child is admitted to the hospital with a diagnosis of acute rheumatic fever. In obtaining a health history from the child's mother, the recent occurrence of which illness is most significant. A. Sore throat B Chickenpox C. Mumps D. influenza
A. Sore throat
The nurse is assessing an adolescent who arrive at the clinic for physical examination before high school starts the atlas and reports trouble hearing, and a constant ringing in the ears which action should the nurse implement first?
Ask about frequent use of earbuds to listen to music.
The mother of three young children calls the clinic concerned about the recent exposure of her oldest child to chickenpox. The nurse should provide the mother with information about the contagious period for chickenpox. What is the contagious period? A. During the eruption of the vesicles, until crusting occurs B. Two days prior to the onset of the rash, until all lesions are crusted C. Ten days prior to the onset of the rash, until formation of the vesicles D. From the onset of the rash, until the rash is healed
B. Two days prior to the onset of the rash, until all lesions are crusted
The nurse is caring for a child with chronic kidney disease who is experiencing renal osteodystrophy. Which outcome should the nurse explain to the parents about the sequels for their child's with renal osteodystrophy ? A. Hypervitaminosis D B. Weight gain. C. Low blood pressure. D. Arrested growth
B. Weight gain.
A one-month old male infant is brought to the clinic by his mother who states that her son has been vomiting forcefully after each meal for the last three days. The infant is afebrile, dehydrated, and pyloric stenosis is suspected. What other findings should the nurse identify that are consistent with pyloric stenosis? A. Perianal diaper rash from persistent diarrhea B. Rooting, hunger, and irritability C. An olive-shaped mass in the abdominal area D Bile-stained emesis
C. An olive-shaped mass in the abdominal area
During the physical exam of an 11-year-old girl, the nurse observes budding breast and scant pubic hair. Which Tanner stage should the nurse choose when documenting these findings? A. V B. II C. III D. IV
C. III
A 2-year-old boy who had hypospadias repair yesterday goes to the hospital playroom with his mother. Which activity should the nurse recommend? A. Peddling a tricycle in the hall B. Riding a rocking horse C. Using a large-piece puzzle D. Paying catch ball with others
C. Using a large-piece puzzle
During a well-baby clinic visit, the mother of a 6-month-old infant asks the nurse if she can have a prescription for poly VI sol with fluoride. Though the infant is still breast feeding, the mother provides the child with supplemental formula feedings. Which assessment is most important for the nurse to obtain? A. The newborn's gestational age assessment B. Weight gain and type of formula taken daily C. Water source used with supplemental feedings D. The infant's current hemoglobin and hematocrit
C. Water source used with supplemental feedings
Following admission for a cardiac catheterization , the nurse is providing discharge teaching to the parents of a 2-year -old toddler with Tetralogy of Fallot Which instruction should the nurse give the parents if their child becomes pale , cool, and lethargic?
Contact the health care provider immediately
A 9 year old boy is diagnosed with diabetes mellitus type 1. which stage of Ericksons theory of psychosocial development is the nurse, addressing when teaching this client about insulin injections?
D. Industry.
The nurse is measuring the frontal occipital circumference (FOC) of a 3- month-old infant, and notes that the FOC has increased 5 inches since birth and the child's head appears large in relation to body size. Which action is most important for the nurse to take next? A. Plot the measurement on the infant's growth chart B. Observe the infant for sunset eyes C. measure the infants head-to-heel length D. Palpate the anterior fontanel for tension and bulging
D. Palpate the anterior fontanel for tension and bulging
The nurse a preparing a 10-year-old child for suturing of a lacerated forehead. Both parents and a 12-year-old sibling are at the child's bedside. Which instructions best supports this family? A. It is best if the sibling goes to the waiting room until the suturing is completed B. All of you should leave while the healthcare provider sutures the child's forehead C While waiting for the healthcare provider, only one visitor may stay with the child D. Please decide who will stay when the healthcare provider begins suturing
D. Please decide who will stay when the healthcare provider begins suturing
The nurse is caring for an infant with ambiguous genitalia and congenital adrenal hyperplasia. which intervention should nurse prioritize?
Record daily weight
An adolescent with seasonal allergies, asthma, and eczema is obtaining a physical and medical clearance for an overnight week-long summer camp. Which action should the nurse prioritize? A. Ensure the client can perform a return demonstration of sunscreen application B. Remind to pack a rescue inhaler with adequate doses of medication C Advise to balance camp activities with rest and stay well-hydrated D Validate the camp counselor's credentials for emergency response
Remind to pack a rescue inhaler with adequate doses of medication
The parents of a child who is diagnosed with Wilms tumor ask the nurse why surgery is necessary for a biopsy is performed. Which information should the nurse provide?
Surgery is necessary to stage the tumor and determine the metastasis to the other sites
The nurse is caring for a toddler with a large unrepaired, ventricle septal defect and heart failure which assessment findings should the nurse expect?
Tachycardia.
the nurse is providing discharge instructions to the parents of a 10-month-old infant who is post hypospadias repair. which information should the nurse include in the teaching?
Take care during diaper changes to prevent dislodging the catheter stent.
the nurse is examining an infant for possible cryptorchidism. which exam technique should be used? a. place the infant in a side-lying position to facilitate the exam b. hold the penis and retract the foreskin gently c. cleanse the penis with an antiseptic soaked pad d. place the infant in a warm room and use a calm approach
d. place the infant in a warm room and use a calm approach
The clinic nurse receives a call from a mother of a 10 year old who reports the her son just returned from summer camp and has developed .... circular red rash on his arm. The mother asked what over the counter is safe to use. How should the nurse respond?
explain the need for the child to have an immediate medical evaluation
The mother of a four year old boy, who has been hospitalized multiple times asks the nurse how can she help her other children who are asking about their brother. To help the siblings cope with their brothers illness which suggestion is best for the nurse to provide his mother?
prepare the children for any changes in their brother before visiting the hospital.
During a follow up clinic visit, a mother tells the nurse that her 5 month old son, who had a surgical correction for tetralogy of Fallot (TOF) has rapid breathing often takes a long time to eat and requires frequent rest periods. The infant is not crying while being held and his growth is in the expected range. which intervention should the nurse implement.? A. Auscultate heart and lungs, while infant is held B. Obtain a 12 lead electrocardiogram. C. Stimulate the infant to cry to produce cyanosis. D. Evaluate infant for failure to thrive. (FTT)
A. Auscultate heart and lungs, while infant is held
The Nurse is caring for a preschool-aged child with congenital heart defect who is admitted with intermittent low-grade fever, fatigue, and weight loss. Further physical assessment findings include a new murmur, splinter hemorrhages under the nails, and painless red lesions on the palms of the hands. Which diagnostic procedure should the nurse prepare the parents to expect the healthcare provider to prescribe? A. Echocardiogram B. Electrocardiogram C. Chest radiography D. Computerized tomography (CT) scan
A. Echocardiogram
A preschool age child diagnosed with a new onset, grade 2 heart murmur is experiencing fatigue and arrives to the clinic with parents for continued diagnostic evaluation. Which planned test should the nurse discuss first with the parents? A. Echocardiogram. B. Holter monitor. C. Radiography of chest. D. Complete blood count.
A. Echocardiogram.
During a well child visit for their child one of the parents who has an autosomal dominant disorder tells the nurse "we don't plan on having any more children since the next baby is likely to inherit this disorder" how should the nurse respond? A. Explain that each individual future child has a 50% chance of inheriting the disorder. B. Confirm that the risk of inheriting the disorder decreases by 50% with each child that the couple has. C. Encouraged a couple to reconsider their decision since the inheritance pattern may be sex linked. D. Acknowledge that the next child will inherit the disorder since the first child did not.
A. Explain that each individual future child has a 50% chance of inheriting the disorder.
A 6-month-old diagnosed with short bowel syndrome, begins eternal feedings yesterday. To maintain normal growth and development od the child during this period, what action should the nurse include in the infant's plan of care? A. Give the infant a pacifier during feedings B. Use sterile technique during feedings C. Speak to the healthcare provider about instituting physical therapy D. Ensure placement of the nasogastric tube with an abdominal X-ray
A. Give the infant a pacifier during feedings
A 10-year-old girl is diagnosed with inflammatory bowel disease (IBD) her mother is concerned that she will experience developmental delays as the result of this disorder. Who should the nurse respond? A. Growth failure is a concern, but developmental delays are not likely to occur B Scheduling a private tutor can help to prevent developmental delays C. She will only experience developmental delays if weight loss cannot be controlled D. She is at high risk for a number of different problems including developmental delays
A. Growth failure is a concern, but developmental delays are not likely to occur
A child is admitted to the hospital with diarrhea. The nurse can expect this child to exhibit which finding? A. Metabolic acidosis. B. Hypercalcemia. C. Metabolic alkalosis. D. Hyper kalemia.
A. Metabolic acidosis.
The nurse is caring for a school-age child with asthma, who is exhibiting decreased breath, sounds nasal flaring and respiratory rate of 40 breaths/minute. Which actions should the nurse take ? (select all that apply.) A. Monitor pulse oximetry B. Start intravenous infusion access. C. Perform oral suctioning. D. Provide humidified oxygen. E. Deliver short, acting beta agonist. F. Lower the head of the bed.
A. Monitor pulse oximetry B. Start intravenous infusion access. D. Provide humidified oxygen. E. Deliver short, acting beta agonist.
The nurse is performing a routine assessment of a 3-year-old at a community health center. Which behavior by the child should alert the nurse to request a follow-up for possible autistic spectrum disorder (ASD)? A. Performs odd repetitive behaviors B. Strokes the hair of a handheld doll C. Has a history of temper tantrums D. Shows indifference to verbal stimulation
A. Performs odd repetitive behaviors
A child diagnosed with Kawasaki disease is brought to the clinic. The mother reports that her child is irritable, refuses to eat, and has skin peeling on both hands and feet. Which intervention should the nurse instruct the mother to implement 1st? A. Place the child in a quiet environment B. Apply location to hands and feet C. Make a list of foods that the child likes D. Encourage the parents rest when possible
A. Place the child in a quiet environment
A 6-year-od male with a body mass index (BMI) in the 95th percentile for gender and age arrives at the clinic after a referral from the school nurse. His laboratory findings include a hemoglobin A1C od 5.5, blood pressure in the 50th percentile for age, height in the 75th percentile, and an LDL, cholesterol of 90 mg.dl. Which lifestyle modification should the nurse discuss with the parents? A. Recommend increasing daily fruits and vegetables and daily exercise B. Return in one month for another evaluation of serum lipids and blood pressure C. Instruct the parents to weight the child weekly and measure his BP daily D. See a healthcare provider to further assess for diabetes and hypertension
A. Recommend increasing daily fruits and vegetables and daily exercise
The nurse is assessing a school-age child, visual equity using a Snellen chart. The child cannot identify several letters and numbers on the chart at a distance greater than 20 feet. which action should the nurse implement ?A. Report the finding to the healthcare provider. B. Listen to the child articulation of common words. C. Use artificial tears in the child's eyes and repeat the test. D. Extra child about the ability to read where is clearly.
A. Report the finding to the healthcare provider.
A 3-year-old child with HIV infection is staying with a foster family who is caring for three other children in their home. When one of the children acquires pertussis, the foster parent calls the clinic and asks the nurse what they should do. Which action should the nurse take 1st? A. Review immunization record of the child with an HIV infect B Place the child with an HIV infection in a protective environment C. Report the exposure of the child with HIV to the health department D. Remove the child with an HIV infection from the foster home
A. Review immunization record of the child with an HIV infect
A male high school student with type 1 diabetes test his blood glucose level before playing a game of soccer, and he obtains a reading of 180 mg/dl (10 mmol/L). Based on this reading, which action should the nurse take? A. Tell him to eat a sandwich and fruit before beginning the game B check his urine for ketones C Give him permission to go ahead and play soccer D call the healthcare provider
A. Tell him to eat a sandwich and fruit before beginning the game
The nurse plans to conduct a physical assessment of a toddler. Which protocol is best for the nurse to implement? A. Ensure that the room is warm and undress the child completely B. Prior to helping the child remove their clothing, use a paper doll to demonstrate removal of clothing C. Have the parent remove the child's outer clothing and remove the diaper or training pants when necessary D. Help the child take off their clothes, removing underwear only to conduct examination of the genitalia
B. Prior to helping the child remove their clothing, use a paper doll to demonstrate removal of clothing
The nurse is caring for a school-age child, diagnosed with bacterial meningitis, who is experiencing fever, irritability, nuchal rigidity. Which action should the nurse prioritize? A. Give prescribe pain medication. B. Administer antibiotic therapy. C. Provide ice packs and antipyretic. D. Limit environmental stimuli.
B. Administer antibiotic therapy.
The nurse is giving an intramuscular injection of an antibiotic to a 16-month toddler with pneumonia. The toddler does not have any known allergies and has been walking without assistance for one-month, Which technique should the nurse select for administration? A. Used a needle length of ½ inch to avoid deep tissue damage B. Administer the injection into the middle of the lateral aspect of the thigh C. Give in the arm, one to 2 inches below the acromion process D. Divide the gluteal area into quarters and give IM into the upper outer quadrant
B. Administer the injection into the middle of the lateral aspect of the thigh
A 2-year-old child with heart failure is admitted for replacement of a graft for coarctation of the aorta. Prior to administering the next dose of digoxin, the nurse obtains an apical heart rate of 128 beats/min. What action should the nurse implement? A. Calculate the safe dose range B. Administer the schedule dose C. Review the serum digoxin level D Determine the pulse deficit
B. Administer the schedule dose
When administering indomethacin to a premature infant who has patent ductus arteriosus, the nurse should anticipate which outcome? A. Decreased urinary output B. Decreased cardiac murmur C. Increased number of RBC D. Increased respiratory effort
B. Decreased cardiac murmur
A 1-year-old child with respiratory initial virus (RSV) is admitted to the pediatric unit. The nurse observes the child presents with a fever, rhinorrhea, frequent coughing and sneezing. Which additional finding should alert the nurse that the child is in acute respiratory distress? A. A resting respiratory rate of 35 breaths/min B. Flaring of the nares C. Bilateral bronchial breath sounds. D. Diaphragmatic respirations.
B. Flaring of the nares
A mother brings her 10-year-old boy who is holding his abdomen to the clinic because of fever, vomiting and abdominal pain for the past 12 hours. which assessment data is most important for the nurse to obtain ? A. His typical pattern and type of bowel movements. B. His description of the quantity and the nature of the pain. C. Activity history 24 hours prior to the onset of pain. D. A Complete blood count, including differential count.
B. His description of the quantity and the nature of the pain.
The school nurse is assessing a child who reports having an itchy scalp. The nurse has sent home care instructions for pediculosis capitis for several children at the school. Which assessment should the nurse implement to this child? A. Determine if silvery crusty scales are seen in skin folds B. Inspect hair follicle shafts for adherence of nits C Observe base of neck and forehead for ring-shaped rash D. Look for raised, reddening areas and balding on scalp
B. Inspect hair follicle shafts for adherence of nits
While administering the final dose or oral amoxicillin to a preschool-aged boy, he tells the nurse that his throat hurts. Which intervention is most important for the nurse to implement? A. Document the child's comments B. Inspect the child's oropharynx C. Review the child's history of sore throat D. Assess skin for signs of allergic reaction
B. Inspect the child's oropharynx
A male child is being prepared for a CT scan when he begins to have a tonic chronic seizure. His mother is hysterical and is trying to hold her child down. What actions should the nurse take (select all that apply) A. Administer and anticonvulsant medication B. Place pillows inside the side rails C. Ask the mother to release the child D. Close blinds room so is darkened E. Monitor the child's airway and tongue
B. Place pillows inside the side rails C. Ask the mother to release the child E. Monitor the child's airway and tongue
When advising a new mother, and caring for a child with croup. Which symptom should be a priority concern to the telephone triage nurse? A. Difficulty swallowing secretions B. Fever 101.0°F (38.3°C.) C. Barking cough worse at night. D. Cries often when the nursing.
C. Barking cough worse at night.
A male infant is admitted to the pediatric unit with pertussis and is exhibiting a "whooping-like-cough." The mother brings the infant to the nurse's station to seek assistance. Which intervention should the nurse implement first? A. Explain the need to maintain droplet precautions to prevent spread to others on the unit B. Give the infant an oral dose of a prescribed antitussive and analgesic/antipyretic C. Cover the infant's mouth and assist the mother to take the infant back to the room D. Ask the mother if a cool mist humidifier at the bedside is functioning and releasing mist
C. Cover the infant's mouth and assist the mother to take the infant back to the room
The nurse is preparing a school age child for potential painful procedure. Which statements should the nurse make to best prepare the child for the procedure? A. Except that they will be pain B. Try not to worry about it C. Expect to feel pinching D. Determined to be brave
C. Expect to feel pinching
The nurse is discharging an adolescent client with sickle cell disease, which client response indicate a need for further teaching about preventing and managing sickle cell crisis? A. Avoid certain kinds of strenuous exercise. B. Take prescribe pain medication when early symptoms of a crisis begin. C. Limit how much fluid to drink to avoid dependence swelling in the feet D. Dress warmly wanna go outside in cold weather.
C. Limit how much fluid to drink to avoid dependence swelling in the feet
The nurse is admitting a child with a diagnosis of untreated, hypothyroidism, which finding indicated of hypocalcemia should the nurse report to the healthcare provider? A. Positive. Goombs test B. Rapid weight gain. C. Muscular weakness D. Positive Chovostek sign
C. Muscular weakness
The teacher notify the school nurse at a child's nose is bleeding for no apparent reason which action should the nurse implement first ? A. Insert a sterile cotton ball in the nearest that is bleeding. B. Apply and ice compress to the child's nose right away. C. Pinched in those using thumb and finger for 10 minutes. D. Tip the child's head back to avoid swelling blood.
C. Pinched in those using thumb and finger for 10 minutes.
A mother of a one month old infant, calls the clinic to report that the back of her infants head is flat. How should the nurse respond? A. Place a small pillow under the infants head while laying on the back. B. Prop the infant, and a sitting position with a cushion we're not sleeping. C. Position the infant on the stomach occasionally one awake and active. D. Turned if it on the left side braced against the curb when sleeping.
C. Position the infant on the stomach occasionally one awake and active.
An infant is admitted for surgery who has Wilms' tumor. Which nursing intervention should the nurse implement during the preoperative period? A. Administer pain medication based on the FACES pain scale B. Include the prone position in the q2h turning schedule C. Give antiemetic medications to prevent nausea and vomiting D. Careful bathing and handling that avoids abdominal manipulation
D. Careful bathing and handling that avoids abdominal manipulation
Which nursing intervention is most important to assist in detecting hypopituitarism and hyperpituitarism in children? A. Assessing for behavioral problems at home and school by interviewing the parents B. Preforming head circumference measurements on infants under one year of age C. Noting a marked weight gain without a gain in height on a growth chart D. Carefully recording the height and weight of children to detect inappropriate growth rates
D. Carefully recording the height and weight of children to detect inappropriate growth rates
The parents of a 4 week old infant fall the pediatric clinic to report that their infant eats well, but vomits after each feeding. To differentiate between the normal regurgitation and pyloric stenosis, which information is most important for the nurse to obtain? A. Level of the infants distress after vomiting B. Older and texture associated with emesis. C. Position of the infant when vomiting occurs. D. Degree of forcefulness of vomiting episodes.
D. Degree of forcefulness of vomiting episodes.
The nurse is discharging a school age child with iron deficiency, anemia. Which instructions regarding liquid or iron supplement should the nurse provide the parents.? A. Makes the iron supplements into a cup of Yogurt B. Give the iron supplement with a large meal. C. Keep the iron supplement in the refrigerator. D. Give the iron supplement through a straw.
D. Give the iron supplement through a straw.
The mother of an 11-year-old boy who has juvenile idiopathic arthritis tells the nurse, " I really don't want my son to become dependent on pain medication, so I only allow him to take it when he is really hurting". Which information is most important for the nurse to provide this mother? A. Encourage quite activities such as watching television as a pain distracter B. The use of hot baths can be used as an alternative for pain medication C. The child should be encouraged to rest when he experiences pain D. Giving pain medications around the clock helps control the pain
D. Giving pain medications around the clock helps control the pain
One week after removing a tick, a student arrives at the school nurse's office with reports of flu-like symptoms. Which intervention should the school nurse implement 1st? A. Observe for a rash around the tick bite site B. Measure the student's oral temperature C. Inform the student of Lyme disease signs and symptoms D. Instruct the student's parents to seek medical attention
D. Instruct the student's parents to seek medical attention
A child admitted with diabetic ketoacidosis is demonstrating Kussmaul's respirations. The nurse determines that the increased respiratory rate is a compensatory mechanism for which acid base alteration? A. Metabolic alkalosis. B. Respiratory acidosis. C. Respiratory alkalosis. D. Metabolic acidosis
D. Metabolic acidosis
The nurse is assessing a preschool age child who presents with flank pain dyspuria and low-grade fever. Which additional information should the nurse gather from the parent to determine a possible urinary tract infection? A. Pale urine B increase fluid intake C. voiding every 4 hours. D. New onset bedwetting
D. New onset bedwetting
When inspecting the spine of a 10-year-old child, a nurse notes curvature at the back of the neck. how should this finding be classified? A. Indicated of skeletal immaturity. B. Abnormal. C. Minor deviation. D. Normal.
D. Normal.
A child with possible Duchenne muscular dystrophy ( MD) undergoes an electromyogram (EMG). Following the procedure, the child's parents tell the nurse that the child is complaining of sore muscle. How should the nurse respond?
Offer a reassurance that muscle soreness following this procedure is temporary and does not indicate a problem.
The nurse is evaluating a young child with atopic dermatitis which question should the nurse asked a parent while updating the child's history?
has a child display any symptoms of asthma or hayfever?
