ATI PEDS TEST A

Tachypnea

-a rapid regular breathing patter -this breathing pattern occurs with anxiety, fever, metabolic acidosis, or severe anemia

A school nurse is assessing an adolescent who has multiple burns in various stages of healing. Which of the following behaviors should the nurse identify as a possible indication of physical abuse

-Denies discomfort during assessment of injuries -the nurse should suspect child maltreatment in the form of physical abuse if the adolescent has a blunted response to painful stimuli or injury

A nurse is reviewing the laboratory report of a 7-year old child who is receiving chemotherapy. Which of the following laboratory values should the nurse report to the provider

-Hgb 8.5 g/dL -A child receiving chemotherapy is at risk for anemia due to the chemotherapy. normal range of hemoglobin for a seven year old is 10 to 15.5 g/dL

Urine specific gravity range

1.005-1.030

Heart rate for a toddler is

=80-120 BPM

McBurney's point

-Pain in RLQ with appendicitis

Average weight of a toddler

-14.5kg (32lbs)

Respiratory rate for a toddler

-20-25 breaths per minute

A nurse is teaching the guardian of a 6-month-old infant about car seat use. Which of the following statements by the guardian indicates an understanding of the teaching

-I should secure the car seat using lower anchors and tethers instead of the seat belt -Lower anchors and tethers, or the LATCH child safety system, should be used to secure an infant's car seat in the vehicle. This system provides anchors between the front cushion and the back rest of the car seat. Therefore, if this system is available, the seat belt does not have to be used

A nurse is teaching a school-age child who has a new diagnosis of type I diabetes mellitus. Which of the following statements by the child indicates an understanding of the teaching

-I will give myself a shot of regular insulin 30 minutes before I eat breakfast -The child should administer regular insulin 30 min before meals so that the onset coincides with food intake

A nurse is teaching the parent of an infant who has a Pavlik harness for the treatment of developmental dysplasia of the hip. The nurse should identify that which of the following statements by the parent indicates understanding of the teaching?

-I will place my infant's diapers under the harness straps -To prevent soiling of the harness, the parent should apply the infant's diaper under the straps

A hospice nurse is caring for a preschooler who has a terminal illness. One of the preschooler's parents tells the nurse that they cannot cope anymore and are thinking about moving out of the house. Which of the following statements should the nurse make

-Let's talk about some of the ways you have handled previous stressors in your life -This statement offers a general lead to allow the parent to express their feelings and previous actions when faced with stressful situations. It also helps the parent to focus on ways that they can cope with the current situation

A nurse is assessing a school-age child who has meningitis. Which of the following findings is the priority for the nurse to report to the provider

-Petechiae on the lower extremities -The presence of petechiae or purpuric rash on a child who is ill can indicate the presence of meningococcemia. This type of rash indicates the greatest risk of serious rapid complications from sepsis and should be reported immediately to the provider

A nurse is reviewing the lumbar puncture results of a school-age child who is suspected of having bacterial meningitis. Which of the following findings should the nurse identify as an indication of bacterial meningitis

-answer: increased protein concentration -rationale: increased protein concentration in the spinal fluid is a finding that can indicate bacterial meningitis

A nurse is preparing to collect a sample from a toddler for a sickle-turbidity test. Which of the following actions should the nurse plan to take

-answer: perform a finger stick -rationale The nurse should perform a finger stick on a toddler as a component of the sickle turbidity test. -if the test is positive, hemoglobin electrophoresis is required to distinguish between children who have the genetic trait and children who have the disease

A nurse is caring for a school age child who is in Buck's traction following a leg fracture 24hrs ago. Which of the following actions should the nurse take

-assess peripheral pulses every 4 hr -Bucks traction is a type of skin traction that can be used to immobilize extremities prior to surgery. The nurse should provide frequent neurovascular checks at least every 4hr after the first 24hr of placement in Buck's traction. The nurse should monitor & report signs of neurovascular impairment in the extremities such as cyanosis, edema, pain, absent pulses, and tingling

A nurse is assessing a 4-year-old child at a well-child visit. Which of the following developmental milestones should the nurse expect to observe.

-cuts an outlined shape using scissors -The nurse should recognize that an expected developmental milestone of a 4-year old child is using scissors to cut out a shape

A nurse is caring for a school age child who is receiving cefazolin via intermittent IV bolus. The child suddenly develops diffuse flushing of the skin and angioedema. After discontinuing the medication infusion, which of the following medication should the nurse administer first

-epinephrine -the child is most likely experiencing an anaphylactic reaction to cefazolin. According to evidence-based practice, the nurse should first administer epinephrine to treat anaphylaxis. Epinephrine is a beta adrenergic agonist that stimulates the heart, causes vasoconstriction of blood vessels in the skin and mucous membranes, and triggers bronchodilation in the lungs

A nurse is caring for a school-age child who is receiving a blood transfusion. Which of the following manifestations should alert the nurse to a possible hemolytic transfusion reaction?

-flank pain -the nurse should recognize that flank pain is caused by the breakdown of RBC's and is an indication of a hemolytic reaction to the blood transfusion

A nurse is providing teaching to the parent of an infant who has diaper dermatitis. The nurse should instruct the parent to apply which of the following to the affected area

-zinc oxide -Diaper dermatitis is a common inflammatory skin disorder caused by contact with an irritant such as urine, feces, soap, or friction, and takes the form of scaling blisters, or papules with erythema. Providing a protective barrier, such as zinc oxide, against the irritant allows the skin to heal

A nurse in an emergency department is performing a physical assessment on a 2-week old male newborn. Which of the following findings is the priority for the nurse to report to the provider

-substernal retractions -rationale is use the ABC's to determine priority

A nurse is assessing a toddler who has gastroenteritis and is exhibiting a manifestation of dehydration. Which of the following findings is the nurse's priority

-tachypnea -When using the airway, breathing, and circulation approach to client care, the nurse's priority finding is the toddler's tachypnea. Tachypnea is a result of the kidneys being unable to excrete hydrogen ions and produce bicarbonate, which leads to metabolic acidosis

A nurse is caring for a preschooler whose father is going home for a few hours while another relative stays with the child. Which of the following statements should the nurse make to explain to the child when their father will return?

- your daddy will be back after you eat -Preschoolers make sense of time best when they can associate it with an expected daily routine, such as meals and bedtime. Therefore, the child comprehends time best when it is explained to them in relation to an event they are familiar with, such as eating.

K+ expected range

-4.1- 5.3

Bun expected range

-5-18 mg/dL

Blood pressure range of a toddler

-86-118 mmHg systolic -44 to 74 mmHg diastolic -

A school nurse is assessing an adolescent who has scoliosis. Which of the following findings should the nurse expect?

-A unilateral rib hump -when assessing an adolescent for scoliosis, the school nurse should expect to see a unilateral rib hump with hip flexion. This results from a lateral S or C shaped curvature to the thoracic spine resulting in asymmetry of the ribs, hips, or pelvis. Scoliosis can be the result of a neuromuscular or connective tissue disorder, or it can be congenital in nature

A nurse is receiving change of shift report for four children. Which of the following children should the nurse see first?

A school-age child who has sickle cell anemia and reports decreased vision in the left eye. -When using the urgent vs. non urgent approach to client care. the nurse should determine the priority finding is a report of decreased vision in the left eye. This finding indicates that the child is experiencing a vaso occlusive crisis and should be reported to the provider immediately.

A nurse in an emergency department is caring for a school-age child who has appendicitis and rates their abdominal pain as 7 on a scale of 0 to 10. Which of the following actions should the nurse take

-Give morphine 0.05 mg/kg IV -A pain level of 7 on a scale of 0 to 10 is considered severe, The nurse should administer an analgesic medication for pain relief

A nurse is preparing to administer an immunization to a 4-year old child. Which of the following actions should the nurse plan to take

-administer the immunization using a 24 gauge needle -the nurse should administer an immunization for a 4-year old child using a 22 to 25 gauge needle to minimize the amount of pain the child experiences

A nurse is planning care for a toddler who has a serum lead level of 4 mcg/dL. Which of the following actions should the nurse plan to take.

-Schedule the toddler for a yearly rescreening -The nurse should schedule the toddler for a lead level rescreening in 1 year and educate the family on ways to prevent exposure

A nurse is reviewing the laboratory report of an infant who is receiving treatment for severe dehydration. The nurse should identify that which of the following laboratory values indicates effectiveness of the current treatment

-Sodium 140 mEq/L -the nurse should identify that a sodium level of 140 mEq.L is within the expected reference range of 134 to 150 mEq/L and indicates the current treatment regimen the infant is receiving for dehydration is effective

A nurse is providing discharge teaching to the parent of a child who is 1 week postoperative following a cleft palate repair. For which of the following members of the interprofessional team should the nurse initiate a referral?

-Speech therapist -The nurse should initiate a referral for a speech therapist for a child who is postoperative following a cleft palate repair. A child who has a cleft palate will require speech therapy immediately following the repair to support speech development and future articulation

A nurse is assessing the vital signs of a 10 year old child following a burn injury. The nurse should identify that which of the following findings is an indication of early septic shock

-Tem of 39.1 102.4 degrees F -the nurse should identify that a temp of 39.1 102.4 is above the expected range of 37 to 37.5 98.6 to 99.5 for a ten year old child. The nurse should expect a child who has early septic shock to have a fever and chills

A nurse is caring for an infant who has respiratory syncytial virus (RSV). Which of the following actions should the nurse implement for infection control

-The nurse should initiate droplet precautions for an infant who has RSV because the virus is spread by direct contact with respiratory secretions

A nurse is interviewing the parent of an 18-month-old toddler during a well-child visit. The nurse should identify that which of the following findings indicates a need to assess the toddler for hearing loss?

-The toddler received tobramycin during a hospitalization two weeks ago -the nurse should identify tobramycin as an aminoglycoside, which is an oto and has a toxic medication that can cause mild to moderate hearing loss, and should assess the toddler for a hearing impairment

A nurse is providing dietary teaching to the parent of a school-age child who has celiac disease. The nurse should recommend that the parent offer which of the following foods to the child?

-White rice -The nurse should recommend that the parent offer white rice to the child because it is a gluten free food. The nurse should instruct the parent that the child will remain on a lifelong gluten-free diet and the child should not consume oats, rye, barley, or wheat, and sometimes lactose deficiency can be secondary to this disease

A charge nurse in an emergency department is preparing an in-service for a group of newly licensed nurses on the clinical manifestations of child maltreatment. Which of the following manifestations should the charge nurse include as a potential indication of physical abuse?

-symmetric burns of the lower extremities -the nurse should include that symmetric burns to the lower extremities can indicate physical abuse. The patterns are usually characteristic of the method or object used, such as cigar or cigarette burns, or burns in the shape of an iron

A nurse is planning care for a school-age child who is in the oliguric phase of acute kidney injury and has a sodium level of 129mEq/L. Which of the following interventions should the nurse include in the plan

-initiate seizure precautions for the child -A sodium level of 129 mEq/L indicates hyponatremia and places the child at increased risk for neurological deficits and seizure activity. The nurse should complete a neurologic assessment and implement seizure precautions to maintain the child's safety

A nurse is caring for a school-age child who has experienced a tonic-clonic seizure. Which of the following actions should the nurse take during the immediate postictal period?

-place the child in a side-lying position -the nurse should place the child in a side-lying position to prevent aspiration

A nurse is providing teaching about play activities for social development to the parents of a preschooler. Which of the following play activities should the nurse recommend for the child

-playing dress up -the nurse should instruct the parents that at the preschool age, play should focus on social, mental, and physical development. Therefore, playing dress-up is a recommended play activity for this child

A nurse is creating a plan of care for a school-age child who has heart disease and has developed heart failure. Which of the following interventions should the nurse include in the plan?

-provide small, frequent meals for the child -the metabolic rate of a child who has heart failure is high because of poor cardiac function. Therefore, the nurse should provide small, frequent meals for the child because it helps to conserve energy.

A nurse is teaching the parent of an infant about ways to prevent SIDS. Which of the following instructions should the nurse include?

-Give the infant a pacifier at bedtime -The nurse should inform the parent that protective factors against SIDS includes breastfeeding and the use of a pacifier when the infant is sleeping

A nurse is caring for a toddler who has spastic (pyramidal) cerebral palsy. Which of the following findings should the nurse expect

-Ankle clonus -The nurse should expect a child who has spastic cerebral palsy to exhibit ankle clonus, which is a rhythmic reflex tremor when the foot is dorsiflexed -Exaggerated stretch reflex -The nurse should expect a child who has spastic cerebral palsy to exhibit spastic or exaggerated stretch reflex -Contractures -The nurse should expect a child who has spastic cerebral palsy to exhibit contractures due to the tightening of the muscles

A nurse in an emergency department is caring for a toddler who has partial-thickness burns on their right arm. Which of the following actions should the nurse take

-Cleanse the affected with mild soap and water -The nurse should wash the affected area with mild soap and water to remove any loose tissue that could cause infection

A nurse in an emergency department is caring for a school-age child who is experiencing an anaphylactic reaction. Which of the following is a priority action by the nurse?

-Administer epinephrine IM to the child -When using the urgent vs. nonurgent approach to client care, the nurse should determine the priority action is administering epinephrine IM to the child. During an anaphylactic reaction, histamine release causes bronchoconstriction and vasodilation. This is an emergency because ultimately this causes decreased blood return to the heart

A nurse is caring for a school-age child who is receiving chemotherapy and is severely immunocompromised. Which of the following actions should the nurse take

-Screen the child's visitors for indications of infection -A child who is severely immunocompromised is unable to adequately respond to infectious organisms, resulting in the potential for overwhelming infection.

A nurse is reviewing the laboratory report of a school-age child who is experiencing fatigue. Which of the following findings should the nurse recognize as an indication of anmeia?

-Hematocrit 28% -The nurse should recognize that this hematocrit level is below the expected reference range of 32-44% for a school age child. The child can exhibit fatigue, lightheadedness, tachycardia, dyspnea, and pallor due to the decreased oxygen carrying capacity

A nurse is caring for an adolescent who received a kidney transplant. Which of the following findings should the nurse identify as an indication the adolescent is rejecting the kidney

-serum creatinine 3.0 mg/dL -creatinine is a byproduct of protein metabolism and is excreted from the body through the kidneys. An elevated serum creatinine level can be an indication that the kidneys are not functioning. The expected creatinine reference range is 0.4 to 0.1 mg/dL

A nurse is providing teaching to the parent of a school-age child who has a new prescription for oral nystatin for the treatment of oral candidiasis. Which of the following instructions should the nurse include

-shake the medication prior to administration -the nurse should instruct the parent to shake the medication prior to administration to disperse the medication evenly within the suspension