peds nclex

A cooling blanket is prescribed for a child with a fever. The nurse prepares to use the cooling blanket and avoids which of the following?

*1. Keeping the child uncovered to assist in reducing the fever*

A nurse provides instructions to the mother of an infant with cleft palate regarding feeding. Which statement by the mother indicates a need for further instructions?

*1. "I need to use a nipple with a small hole to prevent choking."*

A nurse has provided discharge instructions to the mother of an 18-month-old child following surgical repair of hypospadias. Which statement by the mother indicates a need for further instruction?

*1. "I should carry my child by straddling the child on my hip."*

A nurse is providing instructions to the mother of a child with juvenile idiopathic arthritis regarding measures to take if a painful exacerbation of the disease occurs. Which statement by the mother indicates the need for further instruction?

*1. "The full range-of-motion (ROM) exercises must be performed every day, even during the exacerbations."*

A nurse is providing instructions to a child with cystic fibrosis regarding how to perform the "huff" maneuver. The child asks the nurse about the purpose of this type of breathing. The appropriate nursing response is which of the following?

*1. "This type of breathing is used to mobilize secretions so that they can be easily coughed out."*

Antibiotics are prescribed for a child following a myringotomy with insertion of tympanostomy tubes, and the nurse provides instructions to the parents regarding the administration of the antibiotics. Which statement, if made by a parent, would indicate that the instructions were understood?

*1. "We will administer the antibiotics until they are gone."*

A nurse obtains a health history from a mother of a 15-month-old child before administering a measles, mumps, and rubella (MMR) vaccine. Which of the following is essential information to obtain before the administration of this vaccine?

*1. Allergy to eggs*

An adolescent is seen in the emergency department following an athletic injury, and it is suspected that the child sprained an ankle. X-rays are taken, and a fracture has been ruled out. The nurse provides instructions to the adolescent regarding home care for treatment of the sprain and tells the adolescent which of the following?

*1. Apply ice to the injured area for a period of 30 minutes every 4 to 6 hours for the first 24 hours.*

An emergency department nurse is gathering initial data on a child suspected of epiglottitis. The nurse's priority would be to:

*1. Assess for a patent airway.*

A nurse is assigned to care for a child admitted to the hospital with a diagnosis of suspected bacterial endocarditis. The nurse prepares the child for which of the following diagnostic tests that will confirm the diagnosis?

*1. Blood cultures*

A nurse is monitoring a child with a head injury. On data collection, the nurse notes an abnormal flexion of the upper extremities and an extension of the lower extremities. The nurse documents that the child is experiencing:

*1. Decorticate posturing*

A newborn infant is diagnosed with gastroesophageal reflux (GER). The mother of the infant asks the nurse to explain the diagnosis. The nurse plans to base the response on which description of this disorder?

*1. Gastric contents regurgitate back into the esophagus.*

A breast-feeding mother of an infant with lactose intolerance asks the nurse about dietary measures. Which of the following foods would the nurse instruct the mother to avoid?

*1. Hard cheeses*

When checking a child's trochlear nerve function, the nurse would perform which data collection technique?

*1. Have the child look down and in.*

A child has epistaxis. The nurse understands that an appropriate treatment for epistaxis is which of the following?

*1. Have the child sit up and lean forward.*

A nurse is reviewing a health care provider's prescription for a child who was just admitted to the hospital with a diagnosis of Kawasaki disease. Which prescription should the nurse anticipate being part of the treatment plan?

*1. Immune globulin*

A nursing student is preparing a clinical conference, and the topic of the discussion is caring for the child with cystic fibrosis (CF). The student prepares a handout for the group and lists which of the following on the handout?*SELECT ALL THAT APPLY.*

*1. It is a disease that causes mucus formation to be abnormally thick.* *2. It is a chronic multisystem disorder affecting the exocrine glands.* *3. It is transmitted as an autosomal recessive trait.*

A nurse is caring for a child who was burned in a house fire. The nurse assists in developing a plan of care for monitoring the child during the treatment for burn shock. The nurse identifies which of the following assessments as providing the most accurate guide to determine the adequacy of fluid resuscitation?

*1. Level of consciousness*

A nurse is reviewing the laboratory results of a child with aplastic anemia and notes that the white blood cell (WBC) count is 2000 cells/mm3 and the platelet count is 150,000 cells/mm3. Which of the following nursing interventions will the nurse incorporate into the plan of care?

*1. Maintain strict isolation precautions.*

A nurse is checking a child for dehydration and documents that the child is moderately dehydrated. Which of the following symptoms would be noted in determining this finding?

*1. Oliguria*

A child is diagnosed with scarlet fever. A nurse collects data regarding the child. Which of the following is a clinical manifestation of scarlet fever?

*1. Pastia's sign*

A 5-year-old child is admitted to the hospital for heart surgery to repair tetralogy of Fallot. The nurse notes that the child has clubbed fingers, and the nurse knows that this symptom is likely a result of:

*1. Peripheral hypoxia*

A child with a diagnosis of pertussis (whooping cough) is being admitted to the pediatric unit. As soon as the child arrives in the unit, the nurse would first:

*1. Place the child on a pulse oximeter.*

Choose the interventions that a nurse would include when writing a care plan for a child with hepatitis? *SELECT ALL THAT APPLY.*

*1. Providing a low-fat, well-balanced diet* *3. Teaching the child effective hand washing techniques* *5. Instructing the parents about the risks associated with taking medications*

A nurse is monitoring for signs of dehydration in a 1-year-old child who has been hospitalized for diarrhea and prepares to take the child's temperature. Which method of temperature measurement should be avoided?

*1. Rectal*

A nurse reinforces home-care instructions to the parents of a child with celiac disease. Which of the following food items would the nurse advise the parents to include in the child's diet?

*1. Rice*

A nurse is caring for a child recently diagnosed with cerebral palsy. The parents of the child ask the nurse about the disorder. The nurse bases the response to the parents on the understanding that cerebral palsy is:

*1. Temperature 100.9° F*

An 8-year-old boy is being treated with percussion treatments for cystic fibrosis. How would the nurse determine whether the treatment is effective?

*1. The child has a productive cough of thick sputum.*

A child with a tracheal obstruction is brought to the emergency department by emergency medical services. The child aspirated a grape, and the foreign body was removed by direct laryngoscopy. Following the procedure, the nurse plans to inform the mother of the child that:

*1. The child will need to be hospitalized for observation.*

A nurse is providing teaching regarding the prevention of Lyme disease to a group of teenagers going on a hike in a wooded area. Which of the following points should the nurse include in the session? *SELECT ALL THAT APPLY.*

*1. Tuck pant legs into socks.* *2. Wear closed shoes when hiking.* *3. Apply insect repellent containing DEET.* *4. Cover the ground with a blanket when sitting.*

A nurse is providing home care instructions to the mother of a child diagnosed with pneumonia. Which statement by the mother indicates the need for further instructions?

*2. "I can use a warm mist humidifier to keep the secretions loose."*

A nurse reinforces home-care instructions to the parents of a child with hepatitis regarding the care of the child and the prevention of the transmission of the virus. Which statement by a parent indicates a need for further instruction?

*2. "I need to provide a well-balanced, high-fat diet to my child."*

A nurse is reinforcing instructions to the mother of an 8-year-old child who had a tonsillectomy. The mother tells the nurse that the child loves tacos and asks when the child can safely eat one. The nurse makes which response to the mother?

*2. "In 3 weeks".*

A child is diagnosed with lactose intolerance. The child's mother asks the nurse about the disease. The appropriate nursing response is which of the following?

*2. "It is the inability to tolerate sugar found in dairy products."*

A nurse is reviewing the record of a child scheduled for a health care provider's visit. Before data collection, the nurse notes documentation that the child has enuresis. Based on this diagnosis, the nurse plans to focus on which of the following when collecting data?

*2. Bladder function*

A nurse is monitoring for fluid volume deficit in an infant who is vomiting and having diarrhea. The nurse weighs the infant's diaper after each voiding and stool and carefully calculates fluid volume, knowing that:

*2. Each gram of diaper weight is equivalent to 1 mL of urine.*

A nurse is assisting with performing admission data collection on a 2-year-old child who has been diagnosed with nephrotic syndrome. The nurse collects data knowing that a common characteristic associated with nephrotic syndrome is:

*2. Generalized edema*

A 4-year-old child is being transported to the trauma center from a local community hospital for treatment of a burn injury that is estimated as covering over 40% of the body. The burns are partial- and full-thickness burns. The nurse is asked to prepare for the arrival of the child and gathers supplies anticipating that which of the following will be prescribed initially?

*2. Insertion of a Foley catheter*

Which of the following are characteristics of scabies? *SELECT ALL THAT APPLY.*

*2. It appears as burrows or fine, grayish-red lines.* *3. It is transmitted by close personal contact with an infected person.* *4. It is endemic among schoolchildren and institutionalized populations.* *6. Household members and contacts of the infected child need to be treated at the same time that the child is being treated.*

A nurse is reviewing the immunization schedule for a child with human immunodeficiency virus (HIV) infection with the mother. Which of the following will be a component of the instructions that the nurse provides to the mother?

*2. No live virus vaccines should be administered to the child.*

A nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. Choose the interventions that the nurse should perform. *SELECT ALL THAT APPLY.*

*2. Notify the registered nurse.* *4. Prepare to administer morphine sulfate.* *5. Prepare to administer intravenous fluids.* *6. Prepare to administer 100% oxygen by face mask.*

A nurse assigned to care for a child with mumps is monitoring the child for the signs and symptoms associated with the common complication of mumps. The nurse monitors for which of the following that is indicative of this common complication?

*2. Nuchal rigidity*

A nursing instructor asks the nursing student to plan and conduct a clinical conference on phenylketonuria (PKU). The student researches the topic and plans to include which of the following in the conference?

*2. PKU results in central nervous system (CNS) damage.*

A 6-year-old child with leukemia is hospitalized and is receiving combination chemotherapy. Laboratory results indicate that the child is neutropenic, and the nurse prepares to implement protective isolation procedures. Which interventions would the nurse initiate? *SELECT ALL THAT APPLY.*

*2. Place the child on a low-bacteria diet.* *3. Change dressings using sterile technique.* *5. Perform meticulous handwashing before caring for the child.*

A nurse is reviewing the record of a child with a diagnosis of pyloric stenosis. Which data would the nurse expect to note as having been documented in the child's record?

*2. Projectile vomiting*

A male child who had surgery to correct hypospadias is seen in a health care provider's office for a well-baby check-up. The nurse provides instructions to the mother, knowing that which long-term complication is associated with hypospadias

*2. Renal anomalies*

A nursing student is asked to discuss sudden infant death syndrome (SIDS) at the clinical conference being held at the end of the clinical day. The student plans to include which of the following in the discussion during the conference?

*2. SIDS usually occurs during sleep and is more common in premature infants.*

A nurse who is working in the emergency department is caring for a child who has been diagnosed with epiglottitis. Indications that the child may be experiencing airway obstruction include which of the following?

*2. The child thrusts the chin forward and opens the mouth*

A health care provider prescribes intravenous potassium for a child with hypertonic dehydration. The nurse assigned to assist in caring for the child would check which highest-priority item before administration of the potassium?

*2. Urine output*

A nurse is assigned to care for a child with a spica cast. Which action should be avoided when caring for the child?

*2. Using pillows to elevate the head and shoulders*

The mother of a child with juvenile idiopathic arthritis calls the nurse because the child is experiencing a painful exacerbation of the disease. The mother asks the nurse if the child should perform range-of-motion (ROM) exercises at this time. The nurse makes which response to the mother?

*3. "Have the child perform simple isometric exercises during this time."*

A nurse is reinforcing discharge instructions to the mother of a 2-year-old child who has had an orchiopexy to correct cryptorchidism. Which of the following statements, if made by the mother of the child, indicates that further teaching is necessary?

*3. "I'll let him decide when to return to his play activities."*

A nursing student is caring for a child with increased intracranial pressure. On review of the chart, the student nurse notes that a transtentorial herniation has occurred. A nursing instructor asks the student about this type of herniation. Which statement by the student indicates a need for further research about this condition?

*3. "It involves only the anterior portions of the client's brain."*

A nurse is monitoring the daily weight of an infant with congestive heart failure (CHF). Which of the following alerts the nurse to suspect fluid accumulation and thus to the need to notify the registered nurse?

*4. A weight gain of 1 lb in 1 day*

Several children have contracted rubeola (measles) in a local school and the school nurse conducts a teaching session for the parents of the school-children. Which statement, if made by a mother, indicates a need for further teaching regarding this communicable disease?

*3. "The communicable period ranges from 10 days before the onset of symptoms to 15 days after the rash appears."*

A licensed practical nurse (LPN) is assigned to assist in caring for a hospitalized child who is receiving a continuous infusion of intravenous (IV) potassium for the treatment of dehydration. The LPN monitors the child closely and notifies the registered nurse if which of the following is noted?

*3. A decrease in urine output to 0.5 mL/kg/hr*

A 6-month-old infant receives a diphtheria, tetanus, and acellular pertussis (DTaP) immunization at the well-baby clinic. The mother returns home and calls the clinic to report that the infant has developed swelling and redness at the site of injection. Which instruction by the nurse is appropriate?

*3. Apply an ice pack to the injection site.*

A nurse reinforces instructions to the mother about dietary measures for a 5-year-old child with lactose intolerance. The nurse tells the mother that which of the following supplements will be required as a result of the need to avoid lactose in the diet?

*3. Calcium*

A mother brings her 4-month-old infant to the well-baby clinic for immunizations. Which immunizations should be administered to this infant?

*3. DTaP, Hib, IPV, pneumococcal vaccine (PCV)*

A child with croup is being discharged from the hospital. The nurse provides home care instructions to the mother and advises the mother to bring the child to the emergency department if the child:

*3. Develops stridor*

A nurse provides instructions to the mother of a child with impetigo regarding the application of antibiotic ointment. The mother asks the nurse when the child can return to school. Which response by the nurse is accurate?

*3. Forty-eight hours after using the antibiotic ointment*

An adolescent with diabetes mellitus becomes flushed and complains of hunger and dizziness. A blood glucose level is drawn and the results indicate a glucose level of 60 mg/dL. The appropriate intervention is to:

*3. Give the child a glass of fruit juice.*

A nurse is reviewing the health record of an infant with a diagnosis of gastroesophageal reflux. Which clinical manifestation of this disorder would the nurse expect to note documented in the record?

*3. Hiccupping and spitting up after a meal*

A nurse is performing a neurovascular check on a child with a cast applied to the lower leg. The child complains of tingling in the toes distal to the fracture site. Which action should be taken by the nurse?

*3. Notify the health care provider (HCP).*

A nurse is assigned to care for a child who is in skeletal traction. The nurse avoids which of the following when caring for the child?

*3. Placing the bed linens on the traction ropes*

A nurse is reviewing the laboratory results of a child scheduled for tonsillectomy. Which laboratory value would be significant to review?

*3. Platelet count*

The child with cryptorchidism is being discharged after orchiopexy, which was performed on an outpatient basis. The nurse informs the parents about which priority care measure?

*3. Preventing infection at the surgical site*

A nurse is assisting in developing a plan of care for a 10-year-old child diagnosed with acute glomerulonephritis. Following review of the plan of care, the nurse determines that which of the following is the priority for the child?

*3. Promoting bedrest*

A nurse is assisting a health care provider with an assessment of a child with a diagnosis of suspected appendicitis. In assessing the intensity and progression of the pain, the health care provider palpates the child at McBurney's point. The nurse understands that McBurney's point is located midway between the:

*3. Right anterior superior iliac crest and the umbilicus*

A nurse is providing home care instructions to the mother of a child with bacterial conjunctivitis. The nurse should tell the mother:

*3. That the child's towels and washcloths should not be used by other members of the household*

An emergency department nurse is caring for a child brought to the emergency department following the ingestion of approximately one half bottle of acetylsalicylic acid (aspirin). The nurse anticipates that the likely initial treatment will be:

*3. The administration of activated charcoal*

A nurse is assigned to care for an infant with a diagnosis of tricuspid atresia. The nurse plans care, knowing that in this disorder:

*3. There is no communication from the right atrium to the right ventricle.*

A nurse is caring for a hospitalized infant with a diagnosis of bronchiolitis. The nurse positions the infant:

*3. With the head and chest at a 30-degree angle, with the neck slightly extended*

A nurse provides home care instructions to the mother of a child recovering from Reye's syndrome. Which statement by the mother indicates a need for further instruction?

*4. "I need to give frequent, small, nutritious meals if my child starts to vomit."*

A nurse provides home care instructions to the parents of a child with congestive heart failure regarding the procedure for the administration of digoxin (Lanoxin). Which statement, if made by a parent, indicates the need for further instruction?

*4. "If my child vomits after medication administration, I will repeat the dose."*

A mother with human immunodeficiency virus (HIV) infection brings her 10-month-old infant to the clinic for a routine checkup. A health care provider has documented that the infant is asymptomatic for HIV infection. After the checkup, the mother tells the nurse that she is so pleased that the infant will not get HIV. Which response by the nurse is appropriate?

*4. "Most children infected with HIV develop symptoms within the first 9 months of life, and some become symptomatic at some point before the age of 3 years."*

A pediatric nursing instructor asks a nursing student to describe the cause of the clinical manifestations that occur in sickle cell disease. Which is the correct response by the nursing student?

*4. "Sickled cells are unable to flow easily through the microvasculature, and their clumping obstructs blood flow."*

A nurse is providing instructions to a mother of a child with cystic fibrosis regarding the immunization schedule for the child. Which statement should the nurse make to the mother?

*4. "The child will receive the recommended basic series of immunizations along with a yearly influenza vaccination."*

A nurse has reinforced prior teaching of a school-age child who was given a brace to wear for the treatment of scoliosis. The nurse interprets that the client has not fully understood the information presented if the child makes which statement?

*4. "This brace will correct my curve."*

The school nurse notes that the child has a rash and suspects that it is caused by erythema infectiosum (fifth disease). The nurse bases this determination on the observation that the rash results in:

*4. A "slapped-face" appearance*

Acetylsalicylic acid (aspirin) is prescribed for a child with rheumatic fever (RF). The nurse would question this prescription if the child had documented evidence of which condition?

*4. A viral infection*

A nurse employed in an emergency department is instructed to monitor a child diagnosed with epiglottitis. The nurse notes that the child is leaning forward with the chin thrust out. The nurse interprets this finding as indicating:

*4. An airway obstruction*

A nurse is caring for a child with a fracture who is placed in skeletal traction. The nurse monitors for the most serious complication associated with this type of traction by checking for:

*4. An elevated temperature*

An infant is seen in a clinic and is diagnosed with unilateral hip dysplasia. Which finding is associated with this condition?

*4. Asymmetry of the gluteal skin folds when the infant is placed prone and the legs are extended against the examining table*

A nurse is caring for a child with a diagnosis of intussusception. Which of the following symptoms would the nurse expect to note in this child?

*4. Blood and mucus in the stools*

A nursing instructor is observing a nursing student caring for an infant with a diagnosis of bladder exstrophy. The nursing student provides appropriate care to the infant by:

*4. Covering the bladder with a nonadhering plastic wrap*

A nurse is preparing to care for a child with a head injury. On review of the records, the nurse notes that the health care provider has documented decorticate posturing. The nurse plans care, knowing that this type of posturing indicates which of the following?

*4. Dysfunction in the cerebral hemisphere*

A nurse is assisting in preparing a plan of care for a 4-year-old child hospitalized with nephrotic syndrome. Which dietary intervention is most appropriate for this child?

*4. Encourage the child to eat in the playroom.*

A child with croup is placed in a cool-mist tent. The mother becomes concerned because the child is frightened, consistently crying, and tries to climb out of the tent. The appropriate nursing action would be to:

*4. Let the mother hold the child and direct a cool mist over the child's face*

The primary goal to be included in the plan of care for a child who has cerebral palsy is to:

*4. Maximize the child's assets and minimize the limitations.*

A 3-year-old child is brought to the emergency department. The mother states that the child has had flulike symptoms with vomiting and diarrhea for the past 2 days. On data collection the nurse finds that the child's heart rate is slightly elevated and the blood pressure is normal. The child is irritable and crying only a few tears. The mother states that the child's weight before the illness was 33 pounds. The nurse finds the current weight to be 31 pounds. The nurse correctly interprets this as what level of dehydration?

*4. Moderate dehydration*

A nurse is assisting with data collection from an infant who has been diagnosed with hydrocephalus. If the infant's level of consciousness diminishes, a priority intervention is

*4. Palpating the anterior fontanel*

A nurse is assisting a health care provider (HCP) during the examination of an infant with hip dysplasia. The HCP performs the Ortolani maneuver. Which of the following best describes the action/purpose of the Ortolani maneuver?

*4. Reducing the dislocated femoral head back into the acetabulum*

A nursing student is asked to discuss the pathophysiology related to childhood leukemia during a clinical conference and reviews the planned presentation with the nursing instructor. The nursing instructor advises the student to review the disorder before the clinical conference if the student states that which of the following is associated with this type of cancer?

*4. Reed-Sternberg cells are found on biopsy.*

A nurse is reinforcing instructions to the mother of a preschool child who was recently diagnosed with pediculosis capitis (head lice). Which item should be included in discussions to prevent a reinfestation?

*4. Seal nonwashable items in a plastic bag for 2 to 3 weeks in a warm place if they cannot be vacuumed or dry cleaned.*

A nurse is reinforcing information to parents regarding the signs of meningitis. The nurse informs the parents that the primary signs of meningitis include:

*4. Severe headache and neck stiffness*

An infant is suspected to be human immunodeficiency virus (HIV) positive, and the nurse provides information to the parents about the care of their infant. Which of the following indicates to the nurse that the parents need further information about the care of their HIV-positive infant?

*4. The parents plan to use rice cereal to help with watery stools when they occur.*

A nurse is providing information to the family of a child about a synthetic cast that has been applied to the child for the treatment of a clubfoot. Which information should the nurse provide to the mother?

*4. The synthetic cast allows for greater mobility than a plaster cast.*

A health care provider has prescribed oxygen as needed for a 10-year-old child with congestive heart failure (CHF). In which situation would the nurse administer the oxygen to the child?

*4. When drawing blood for the measurement of electrolyte levels*

The health care provider prescribes laboratory studies for an infant of a woman positive for human immunodeficiency virus (HIV) to determine the presence of HIV antigen in the infant. The nurse anticipates that which laboratory study will be prescribed for the infant?

*4. p24 antigen assay*