Ch. 30

The nurse is caring for a child with an ileostomy. What nursing intervention will be included in this child's plan of care? B. Check for leakage around the stoma. D. Apply a sterile dressing around the stoma. C. Leave the ileostomy open to the air. A. Clean the outside of the collection device.

B. Check for leakage around the stoma.

The nurse is helping assist the care provider in doing a lumbar puncture on a 9-month-old infant. Which method will be the safest and most appropriate method of restraining the child? D. Use a jacket restraint to keep the child snugly held to a bed or gurney. B. Wrap the child in a mummy restraint, then place your hands over the infant's hands tightly on top of the restraint. C. Show the caregiver how to hold the child in a seated position securely on the caregiver's lap. A. Hold the child snugly against the chest, pass one arm below the child's legs; with the other arm, hold the child's hands.

A. Hold the child snugly against the chest, pass one arm below the child's legs; with the other arm, hold the child's hands.

After the provider has written a prescription for the use of heat therapy, the nurse will apply heat using a K-pad or heating pad as ordered. Which of the following is most accurate regarding the use of heat therapy? C. Heat should be used 1 hour at a time and then removed. A. Heat is a vasoconstrictor and decreases circulation. B. Heat may be used to prevent swelling. D. Heat causes muscle relaxation and decreases pain.

D. Heat causes muscle relaxation and decreases pain.

The nurse is caring for a 5-year-old hospitalized child who needs to have blood drawn for the third time. When the lab technician arrives, the child says to the nurse, "You can't take my blood, my mama isn't here." The child's caregiver is not in the hospital and is not expected to return for several hours. Which action taken by the nurse would best meet the needs of the child while supporting medical treatment? A. Check with the floor administrator to see if the blood draw can wait until the caregiver returns. D. Remind him that he has said that before and that he knows that the blood must be taken. B. Recognize the statement is a stalling technique, reassure the child, and continue with the procedure. C. Tell the child that if he will let the phlebotomist take his blood without putting up a fuss, he will get a lollipop.

B. Recognize the statement is a stalling technique, reassure the child, and continue with the procedure.

A young client has a temperature of 102 ℃ (38.9 ℃). In addition to the scheduled antipyretic the child received, the nurse is treating the fever with nonpharmacologic methods by removing the blanket that covers the child. What is the rationale for this action? C. The blanket soaks up the sweat, making the child warmer. D. Covering the child with a blanket leads to shivering, which will only generate more heat. B. Removing excess coverings allows for evaporation, which aids in cooling the child. A. The blanket adds heat to the child.

B. Removing excess coverings allows for evaporation, which aids in cooling the child.

A 5-year-old client is scheduled to have an influenza injection before being discharged from the hospital. When the nurse explains what she has to do, the client begins to cry and asks the nurse if she can have the shot after her movie is over in 2 hours. Which response by the nurse would be the best choice for the client? B. Tell the child that you need to give her the injection now. A. Agree to postpone the injection until after the movie is done. D. Offer to contact the pediatrician's office to have it given at the next visit. C. Negotiate with the child to give the injection in 1 hour.

B. Tell the child that you need to give her the injection now.

The nurse is caring for a child with an elevated temperature. Which of the following nursing interventions would be the highest priority in caring for this child? D. The nurse should keep the temperature of the child's room cool. B. The nurse should monitor the child for seizure activity. C. The nurse should encourage oral fluids at frequent intervals. A. The nurse should dress the child in lightweight clothing.

B. The nurse should monitor the child for seizure activity.

A child is undergoing a painful procedure and is upset. Which statement by the nurse would be the best approach in dealing with the child? A. "If you hold still and be quiet, I will give you a popsicle." D. "Please don't bite or kick me; that would be very naughty." B. "You were brave and good, so you get a sucker." C. "I know that this hurts some but you are being so strong. It is OK to cry."

C. "I know that this hurts some but you are being so strong. It is OK to cry."

A urine specimen has been ordered for a 1-year-old girl. Which method would be the best way for the nurse to obtain this urine specimen? C. Place a sterile cotton ball into the child's diaper; after the child has urinated, squeeze the urine from the cotton ball into a sterile container to be sent to the lab. B. Give the child some water or juice, leave off her diaper, ask the caregiver to call you when the child needs to void, and obtain the specimen in a sterile container. D. Get down on the child's level and speak to her explaining that you need her to tell you when she needs to use the bathroom and when she does, obtain the specimen. A. Clean the child's genital area thoroughly and when she has urinated, squeeze the urine from her diaper into a specimen cup.

C. Place a sterile cotton ball into the child's diaper; after the child has urinated, squeeze the urine from the cotton ball into a sterile container to be sent to the lab.

The nurse is teaching a group of first-time parents who are being discharged with their newborns. One parent asks the nurse what to do if the child has a temperature. After conducting teaching regarding how to care for a child with an elevated temperature, the caregivers make the following statements. Which statement would indicate a need for further teaching?

D. "If my child starts to shiver I will know that what I am doing is working and that her fever will soon come down."

A toddler is being discharged home with oxygen by nasal cannula. In educating the parents about oxygen safety, which statement by the father indicates that further teaching is needed? A. "We will keep all flammable materials out of his room." D. "We will let him play with his Leap Frog tablet to keep him entertained." B. "They showed us how to wash the equipment to keep down bacteria." C. "I will use only cotton blankets in his bed for sleeping."

D. "We will let him play with his Leap Frog tablet to keep him entertained."

A child on oxygen reports a "sore nose" and the nurse assesses that the child is experiencing dry nasal passages. What action can the nurse take to help relieve the child's discomfort? D. Use a water-based gel or spray for lubrication of the dry nasal passages. B. Apply a petroleum-based lubricant such as Vaseline on and around the nose to ease the discomfort. A. Turn the oxygen flow rate down to reduce the amount of air passing through the child's nose. C. Place lotion on a cotton swab and gently place some inside each nostril to moisturize the nasal passages.

D. Use a water-based gel or spray for lubrication of the dry nasal passages.

The nurse is caring for a preschool-aged child who is used to being able to get out of bed at any time. Which of the following restraints would be the most appropriate for the nurse to ensure the child remains in the bed? B. clove-hitch restraint A. mummy restraint C. elbow restraint D. jacket restraint

D. jacket restraint

The nurse is assigned to care for a child diagnosed with a chronic illness. The child has just been admitted but has been on the unit many times before. From the report the admitting nurse gives, the child is sicker than the last time she was admitted. In planning the child's care, the nurse notes that the provider has ordered a nasogastric gavage feeding, but the nurse remembers that even the last time the child was on the unit, she was unable to tolerate the nasogastric feedings. The most appropriate nursing action would be for the nurse to: D. talk with the health care provider and request further instruction and orders. A. begin the nasogastric gavage feeding to see if the child can tolerate it. C. ask the nursing supervisor to decide which type of feeding to give. B. begin an orogastric gavage in hopes the child can handle the feeding.

D. talk with the health care provider and request further instruction and orders.

The nurse is helping the care provider with a scalp venipuncture on an infant. Which of the following restraints would be most appropriate for this procedure? C. elbow restraint A. mummy restraint B. clove-hitch restraint D. jacket restraint

A. mummy restraint

As part of the admitting process for a child on the pediatric unit, the nurse instills a small amount of saline into the nose, aspirates, and then places the solution into a sterile specimen container. What is the most likely reason this will be done? C. to remove a foreign body B. to clear the nasal passages D. to detect the presence of old blood A. to diagnose an infection

A. to diagnose an infection

The nurse is administering a gavage feeding through a nasogastric feeding tube. Which nursing intervention is the highest priority? A. The nurse positions the child in a sitting position. C. The nurse replaces stomach content that has been aspirated. B. The nurse verifies the position of the feeding tube. D. The nurse documents how the child tolerated the feeding.

B. The nurse verifies the position of the feeding tube.

The nurse is teaching a couple who are first-time parents. They are being discharged with their newborn. The mother tells the nurse she has heard about sudden infant death syndrome and is worried about that happening to her baby. In teaching about the prevention of SIDS, the nurse teaches the new parents to: A. let the newborn sleep on his stomach in their bed. B. prop the baby on his side or put him to sleep on his back. C. lay him on his stomach with a small pillow under his abdomen. D. prop him up with a pillow so his head is at a slightly elevated angle.

B. prop the baby on his side or put him to sleep on his back.

Tess is a 5-year-old client who must receive an IV infusion of antibiotics. She is anxious, resistant, and wiggly. To keep her safe during the time the IV is in place, the nurse would choose which method to restrain her? C. Use a clove-hitch restraint to keep her arm still and loosen it every 2 hours. A. Restrain her with a mummy restraint and loosen and rewrap it every 3 hours. B. Restrain her on a papoose board and release her as soon as the IV is in place. D. Allow her caregiver to hold her during the time the IV is in place.

C. Use a clove-hitch restraint to keep her arm still and loosen it every 2 hours.

The nurse is conducting teaching with the caregivers of a child who is being discharged from the pediatric unit. The care provider has recommended the child have moist heat applications at home. In conducting teaching with this caregiver, the nurse will teach the caregiver to use which of the following to provide the moist heat? B. towels dampened and heated in the microwave C. a hot water bottle D. towels dampened with hot water A. an electric heating pad

D. towels dampened with hot water