Exam 2- possible questions 4
A nurse is caring for an infant who is receiving IV fluids for the treatment of tetralogy of fallot and begins to have a hypercyanotic spell. Which of the following actions should the nurse take?
Place the infant in a knee-chest position-- this will decrease the return of desaturated venous blood from the legs and to direct more blood into the pulmonary artery by increasing systemic vascular resistance
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 to the child-- the metabolic rate for a child with heart failure is high because of poor cardiac function and helps conserve energy
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-- potential for an overwhelming infection
A nurse is assessing an infant who has a ventricular septal defect. Which of the following findings should the nurse expect?
Loud, harsh murmur-- due to the left-to-right shunting of blood
A nurse is caring for a school-age child who has acute rheumatic fever. Which of the following actions should the nurse take?
Maintain the child on bed rest-- limiting activity with assist with prevention of cardiac damage
A nurse is providing discharge teaching to the parents of a 6-month-old infant who is postoperative following hypospadias repair with a stent placement. Which of the following instructions should the nurse include in the teaching?
Allow the stent to drain directly into your infant's diaper-- this will prevent kinking or twisting that can interfere with urine flow
A nurse is admitting a 4-month-old infant who has heart failure. Which of the following findings is the nurse's priority?
Episodes of vomiting-- this can indicate digoxin toxicity which requires immediate intervention
A school nurse is assessing a school-age child who has erythema infectiosum (fifth disease). Which of the following findings should the nurse expect?
Facial rash-- predominantly on the child's cheeks, the rash lasts from 1 to 4 days
A nurse is assessing a toddler who has gastroenteritis and is exhibiting manifestations of dehydration. Which of the following findings should the nurse address first?
Tachypnea-- results when the kidneys are unable to excrete hydrogen ions and produce bicarbonate leading to metabolic acidosis
A nurse is reviewing the laboratory report of a 6-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-- child getting chemo is at risk for anemia due to chemo effects on the blood forming cells of the bone marrow.
A nurse is planning care for a school-age child who is in the oliguric phase of acute kidney injury (AKI) and has a sodium level of 129 mEq/L. Which of the following interventions should the nurse include in the plan?
Initiate seizure precautions for the child-- hyponatremia increases the child's risk of seizures
A nurse is caring for a toddler who is experiencing acute diarrhea and has moderate dehydration. Which of the following nutritional items should the nurse offer to the toddler?
Oral rehydration solution-- this will replace electrolytes and water
A nurse is assessing a toddler who has leukemia and is receiving his first round of chemotherapy. Which of the following findings is the priority for the nurse to report to the provider?
Urticaria-- greatest risk is anaphylactic reaction
A nurse is admitting an infant who has intussusception. Which of the following findings should the nurse expect? Select all that apply
Vomiting-- due to the obstruction that occurs Lethargy-- due to episodes of severe pain
A nurse is teaching a school-age child and his parent about postoperative care following cardiac catheterization. Which of the following instructions should the nurse include?
Wait 3 days before taking a bath-- reduces the risk of infection
