N3710 Final Practice Questions

A 12-year-old client had abdominal surgery to correct a volvulus. The client is receiving 1000 mL of lactated Ringer's solution via a central line infusion. The health care provider orders the maintenance IVF to be infused at 125 ml/hr via a pump and replacement fluids to be infused over 4 hours for the previous 4 hours of output. The output for the previous 4 hours was 200 ml via Foley catheter, 50 ml via nasogastric tube, and 10 ml via Jackson-Pratt tube. What rate will the nurse set the IV pump to deliver in ml/hr for the next 4 hours?

190 ml/hr

The child has been diagnosed with severe dehydration. The provider has prescribed a bolus of 20 mL/kg of normal saline to be administered over a 2-hour period. The child weighs 63.5 lb. What rate will the nurse set the child's IV pump? Record your answer using a whole number.

289

The nurse is preparing to administer a 75% strength tube-feeding formula. The full-strength formula is available. To prepare 500 ml of feeding, the nurse would plan to dilute how many ml of the full-strength formula with water. Record your answer as a whole number.

375 mL

The nurse is caring for an 8-month-old child in Bryant's traction due to a congenital anomaly of the hips. Which are potential complications of traction that the nurse should be aware of? Select all that apply. a. muscle strain b. decubitus ulcer c. diarrhea d. constipation e. urinary tract infection

Answer: a, b, d, e

Which of the following signs would the nurse recognize as an indication of moderate dehydration in a toddler? a. Decreased urine specific gravity b. Weight loss of greater than 10% c. Dry mucous membranes d. Vomiting and diarrhea

Dry mucous membranes

A child returned from the PACU following an appendectomy. Based on the provider's prescriptions, which antibiotic will the nurse administer first? a. Ceftriaxone 1000 mg IV q 12 hrs b. Metronidazole 500 mg IV q 6 hrs c. Ondanestron 2 mg IV q 6 hrs prn d. Morphine sulfate 2 mg IV q 2 hrs prn

Metronidazole 500 mg IV q 6 hrs

An 8-year-old client just returned from the PACU after abdominal surgery. Patient rates pain as an 8 on the FACES scale. Last dose of morphine given 3 hours ago. Place the provider's prescriptions in the order that the nurse should implement them going from the highest priority to the lowest priority. _____a. Vital signs every 30 minutes x2, every 1 hour x2, every 2 hours x 2, and then every 4 hours _____b. Intravenous fluids: D51/2 Normal saline at 75 ml/hr _____c. Ceftriaxone 500 mg IV every 12 hours _____d. Replace NG drainage cc/cc every 4 hours with D51/4 NS _____e. Administer morphine 2 mg IV push prn

a, b, e, c, d Using the ABC's, vital signs will be first because the respiratory and cardiac status need to be assessed first before interventions begin. Next the IVF should be started since that is important for adequate circulation. The third prescription that should be implemented is for pain management since that is "G" in the prioritization system and the pain rating is high at 8. This intervention would be followed by beginning the antibiotic administration to prevent infection. Post-op patients are at risk for developing infections from the incision. Finally, NG drainage will need to be replaced every 4 hours. Since the patient just returned from PACU, there has not been 4 hours of output yet to replace.

A nurse is teaching a group of parent about fractures. Which of the following should be included in the teaching? a. "Epiphyseal plate injuries may result in altered bone growth." b. "Children need a longer time to heal from a fracture than an adult." c. "Bones are unable to bend, so they break." d. "A greenstick fracture is a complete break in the bone."

a. "Epiphyseal plate injuries may result in altered bone growth."

The nurse is working with the mother of a toddler experiencing constipation. What information regarding childhood constipation should the nurse share with the mother? Select all that apply. a. "Have your son sit on the toilet twice a day, after breakfast and dinner, for 5 to 15 minutes." b. "Reward your child with a sticker only when they have a bowel movement." c. "If your child has a fecal impaction, you can give him an enema." d. "Reward your child for sitting on the toilet as asked, not just for having a bowel movement." e. "Do not give your son any laxatives."

a. "Have your son sit on the toilet twice a day, after breakfast and dinner, for 5 to 15 minutes." c. "If your child has a fecal impaction, you can give him an enema." d. "Reward your child for sitting on the toilet as asked, not just for having a bowel movement."

The nurse is providing education to the parents of a teenaged boy diagnosed with impetigo. Which of the following statements by the boy indicates the need for further education? a. "I will need to cover my son's skin lesions with bandages until it has healed." b. "It is important to remove the crusts before applying any topical medications." c. 'This condition is contagious." d. "My son can continue to attend school while he is taking the prescribed antibiotics."

a. "I will need to cover my son's skin lesions with bandages until it has healed."

The nurse is discussing the use of over-the-counter ointments to manage a mild case of diaper rash. What ingredients should the nurse instruct the parents to look for in a compound? Select all that apply. a. Vitamin A b. Zinc c. Vitamin D d. Vitamin B6 e. Vitamin B12

a. Vitamin A c. Vitamin D

A nurse assessing a 6-month-old infant with an integumentary disorder. The nurse notes three identically-sized, round red circles with scaling that are symmetrically spaced on both of the girl's inner thighs. What should the nurse ask the mother? a. "Has she been exposed to poison ivy?" b. "Does she wear sleepers with metal snaps?" c. "Do you change her diapers regularly?" d. "Tell me about your family history of allergies."

b. "Does she wear sleepers with metal snaps?"

A parent calls the nurse advice line to ask about the clinical manifestations associated with roseola. What is the best response by the nurse? a. "Obvious sickness, fever, and rash." b. "Fever for 3 to 4 days, followed by a rash." c. "Rash, without history of fever or sickness." d. "Rash for 3 to 4 days, followed by a high fever."

b. "Fever for 3 to 4 days, followed by a rash."

A child is admitted to the hospital and is undergoing testing for ulcerative colitis. Which symptom would the nurse most likely identify during this initial diagnosis? a. Fecal impaction b. Bloody diarrhea c. Watery diarrhea d. Bloody constipation

b. Bloody diarrhea

Which of the following findings would be most concerning for the neonate who is being treated with caffeine for apnea of prematurity? a. Heart rate of 170 b. Urinary output of 30 cc/hr c. Irritability when diaper changed d. No bowel movement in last 24 hours

b. Urinary output of 30 cc/hr

The nurse is preparing a class for parents of infants about managing diaper dermatitis. What advice would the nurse include in the teaching? Select all that apply. a. Applying topical nystatin to the diaper area. b. Using a blow dryer on warm to dry the diaper area. c. Refraining from using rubber pants over diapers. d. Using scented diaper wipes to clean the area. e. Washing the diaper area with an antibacterial soap.

b. Using a blow dryer on warm to dry the diaper area. c. Refraining from using rubber pants over diapers

A 16-year-old male with structural scoliosis has Harrington rods inserted. Following routine postop care, the nurse monitors the following lab values. Three days postop, which of the following lab values would the nurse report to the health care provider? a. Hemoglobin 14 gm/dL & Hematocrit 41% b. White blood cells 17,000 c. Serum sodium 135 mEq/L & Potassium 4.0 mEq/L d. Platelet count 400,000

b. White blood cells 17,000

The nurse is preparing a toddler for discharge following treatment for diarrhea. What instruction would the nurse most likely include in the discharge teaching? a. "Implement clear liquids." b. "Provide plenty of 100% fruit juice." c. "Encourage a bland diet." d. "Offer flavored gelatin if hungry."

c. "Encourage a bland diet."

The nurse is providing care for a 14-year-old girl with severe acne. The girl expresses sadness and distress about her appearance. Which response by the nurse would be most appropriate? a. "Are you using your medicine every day?" b. "Your condition will most likely improve in a year or two." c. "Many people feel this way; I know someone who can help." d. "If you have any scarring you can undergo dermabrasion."

c. "Many people feel this way; I know someone who can help."

Following repair of a cleft lip in a 3-month-old female infant, the mother asks the nurse what would be the most appropriate toy to bring the infant. What is the best response? a. A plastic teething ring b. A stuffed animal c. A mobile to hang over the crib d. A doll from the movie Frozen

c. A mobile to hang over the crib

Nursing assessments in infants with gastroenteritis should be directed toward detecting which potential problem? a. Urinary retention b. Heart failure c. Electrolyte imbalance d. Hyperactive reflexes

c. Electrolyte imbalance

To prevent tissue infection and breakdown after cleft palate or lip repair, a nurse should use which of the following interventions? a. Keep the suture line moist at all times b. Allow the infant to suck on the pacifier c. Rinse the infant's mouth with water after each feeding d. Feed the infant by nasogastric tube

c. Rinse the infant's mouth with water after each feeding

A child is admitted with scarlet fever. Which of the following causative agents does the nurse identify as a contributor to this infection? a. Roseola b. Staphylococcal parotitis c. Streptococcal pharyngitis d. Varicella

c. Streptococcal pharyngitis

A mother of a 5-month-old infant is planning a trip to the beach and asks for advice about sunscreen for her infant. Which instruction should the nurse give the mother? a. The sunscreen protection factor (SPF) of the sunscreen should be at least 10. b. Apply sunscreen to the exposed areas of the skin and avoid the eyes and mouth. c. Sunscreen should not be applied to infants younger than 6 months of age. d. Sunscreen needs to be applied heavily only once ½ hour before exposure to sun.

c. Sunscreen should not be applied to infants younger than 6 months of age.

The nurse is assessing a newborn infant for dehydration. Which finding indicates severe dehydration? a. Pale and slightly dry mucosa b. Blood pressure of 80/42 c. Tenting of the skin d. Soft and flat fontanels

c. Tenting of the skin Blood pressure of 80/42 and fontanels that are soft and flat are normal findings for a newborn. Pale and slightly dry mucosa indicates dehydration but not severe dehydration. Tenting of the skin indicates severe dehydration.

Which activity in a child with muscular dystrophy should the nurse anticipate that the child will have difficulty with first? a. Sitting b. Breathing c. Swallowing d. Standing

d. Standing

A neonate is admitted to the NICU with imperforated anus, tracheoesophageal fistula, and a single umbilical artery. A nurse suspects which of the following congenital disorders? a. Beckwith-Wiedemann syndrome b. Trisomy 12 c. Turner's syndrome d. VATER association

d. VATER association

The nurse is caring for an infant with pyloric stenosis. Which laboratory value would the nurse expect to find? a. pH 7.30; chloride 120 mEq/L b. pH 7.38; chloride 110 mEq/L c. pH 7.43; chloride 100 mEq/L d. pH 7.49; chloride 90 mEq/L

d. pH 7.49; chloride 90 mEq/L

All of the following are signs of sepsis in the neonate except: a. Lethargy b. Tachypnea c. Hypothermia d. Hypoglycemia e. Sunken fontanel

e. Sunken fontanel

A 2-month-old has been diagnosed with gastroesophageal reflux (GER). Which statements by the parent indicate that further teaching is needed? Select all that apply. a. "I should prop my baby up on a pillow in bed with me after feedings." b. "I do not need to add rice cereal to the feedings until the baby is at least 4 - 6 months old." c. "I will use a bottle with a one-way valve and wide base for feedings." d. "I will burp my baby only at the end of the feeding to prevent the baby from vomiting." e. "I will introduce apple juice to the baby's diet now because it is easier to digest than formula."

a. "I should prop my baby up on a pillow in bed with me after feedings." b. "I do not need to add rice cereal to the feedings until the baby is at least 4 - 6 months old." d. "I will burp my baby only at the end of the feeding to prevent the baby from vomiting." e. "I will introduce apple juice to the baby's diet now because it is easier to digest than formula."

The nurse determines further teaching is not needed when the mother of a child with celiac disease makes which statement? a. "I won't serve wheat, rye, or barley." b. "I will provide a diet high in gluten." c. "I won't serve potatoes, rice or corn bread." d. "I can safely serve any frozen or packaged food."

a. "I won't serve wheat, rye, or barley."

hat hourly rate would the nurse expect the physician to order for the maintenance fluids of D5 ½ NS with 20 mEq KCl for a child weighing 31 pounds? a. 50 mL/hr b. 70 mL/hr c. 72 mL/hr d. 75 mL/hr

a. 50 mL/hr

The charge nurse in the NICU is preparing assignments for a senior practicum student who wants to observe a CT scan. The charge nurse expects which of the following neonates to be screened by CT scan to rule out a diagnosis of intraventricular hemorrhage? a. A 8-day old premie born at 29 weeks gestation. b. A 1-day old premie born to an adolescent mother. c. A 5-day old premie born at 32 weeks gestation. d. A 3-day old premie born to a mother who is 45-years-old.

a. A 8-day old premie born at 29 weeks gestation.

Which of the following findings would the nurse assess in the premature neonate who may have necrotizing enterocolitis? a. Abdominal distention and gastric retention b. Gastric retention and guaiac-negative stools c. Metabolic alkalosis and abdominal distention d. Guaiac-negative stools and metabolic alkalosis

a. Abdominal distention and gastric retention

A nurse is working in her garden when a neighbor frantically comes over and states her child has been bitten on the hand by the new neighbor's dog. What is the first action the nurse should take? a. Assess the wound for depth of injury and bleeding. b. Cleanse the wound and apply an antibacterial ointment. c. Advise the mother to contact the health care provider now. d. Contact EMS for immediate transport to the ED.

a. Assess the wound for depth of injury and bleeding.

The nurse is aware that an infant who had surgical repair of a tracheoesophageal fistula is most at risk for which of the following? a. Atelectasis b. Choking during feeding attempts c. Vocal cord damage d. Infection

a. Atelectasis

The nurse is teaching a group of parents whose children were recently diagnosed with cerebral palsy. Which statement indicates that the teaching was effective? a. "Cerebral palsy occurs because of too much oxygen to the brain during the first trimester of pregnancy." b. "It is a condition that is hereditary and is passed down through the mother." c. "Cerebral palsy means that there are many disabilities with the muscles, nerves, and bones." d. "It is a condition that does not get worse over time."

a. Femoral head loses contact with the acetabulum and is displaced posteriorly.

Which finding would a nurse expect in a child with developmental dysplasia of the hip (DDH)? a. Femoral head loses contact with the acetabulum and is displaced posteriorly. b. Femoral head maintains contact with acetabulum, but there is capsular rupture present. c. Ligamentum teres is shortened. d. Femoral head loses contact with acetabulum and is displaced inferiorly.

a. Femoral head loses contact with the acetabulum and is displaced posteriorly.

Which of the following is a risk factor for developing retinopathy of prematurity? a. Hyperoxemia b. Sepsis c. Hypoxia d. Bronchopulmonary dysplasia

a. Hyperoxemia

The nurse is discussing dietary intake with the parents of a 4-year-old child who has been diagnosed with atopic dermatitis. Later the nurse notes the menu selection made by the parents for the child. Which selection indicates the need for further instruction? a. Peanut butter and jelly sandwich b. Chicken nuggets c. Tomato soup d. Carrot and celery sticks

a. Peanut butter and jelly sandwich

The nurse is caring for a child with tinea pedis. Which of the following assessment findings would the nurse expect to note? a. Red scaling rash on soles and between toes b. Patches of scaling in the scalp with central hair loss c. Inflamed boggy mass filled with pustules d. Erythema, scaling, maceration in the inguinal creases and inner thighs

a. Red scaling rash on soles and between toes

The nurse instructs the parents about postoperative feeding after their infant's pyloromyotomy. The nurse evaluates that the parents understand the instructions when the parents state that they will do which of the following? a. Slowly increase the volume offered according to the provider's instructions. b. Avoid burping the infant after feeding to prevent vomiting. c. Rock the infant to sleep after feeding to keep the infant calm. d. Maintain the infant on antiemetics to prevent vomiting.

a. Slowly increase the volume offered according to the provider's instructions.

A newborn is suspected of having a cardiopulmonary disorder. Which of the following symptoms of persistent pulmonary hypertension should the nurse assess for in the newborn? a. Systolic ejection murmur b. Respiratory alkalosis c. Rhinorrhea d. Lacrimation

a. Systolic ejection murmur

In teaching a group of parents about monitoring for urinary tract infection in preschoolers, the nurse would mention which finding as most indicative of the need to have the child evaluated? a. The child exhibits incontinence after being toilet trained. b. The child voids only twice in any 6-hour period. c. The child has difficulty sitting still for more than a 30-minute period. d. The child's urine smells strongly of ammonia after it stands for more than 2 hours.

a. The child exhibits incontinence after being toilet trained.

The nurse is caring for a child with a skin disorder. The child presented with papules that progressed to vesicles with a honey-colored exudate. What treatment would the nurse expect to be ordered to treat this disorder? Select all that apply. a. Topical mupirocin ointment b. Warm compresses after washing with soap and water several times a day c. Cool compresses to assist in removing crusts on vesicles d. Oral cephalexin e. Regular hygiene measures

a. Topical mupirocin ointment c. Cool compresses to assist in removing crusts on vesicles d. Oral cephalexin

A nurse is explaining physiologic hyperbilirubinemia to the parents of a neonate. Which statement by one of the parents would demonstrate a correct understanding of the concept? a. "Babies with this problem usually also have another medical problem." b. "In a full term baby, it usually starts after 24 hours." c. "It's caused by high levels of conjugated bilirubin." d. "It's usually starts in the baby's feet and moves up to the head."

b. "In a full term baby, it usually starts after 24 hours."

The nurse is providing instructions to the parents of a child who has undergone a barium swallow along with an upper and lower GI for suspected inflammatory bowel disease. Which instructions are most important? a. "Please be aware of any signs of infection such as redness, swelling or discharge with mucus." b. "It is important to drink lots of water and fluids after the test is finished." c. "Your child may have diarrhea for several days afterwards until the barium has passed." d. "Your child might have lighter stools for the next few days."

b. "It is important to drink lots of water and fluids after the test is finished."

A parent calls the school nurse to ask when her child who developed chickenpox can return to school. What is the most appropriate response by the school nurse? a. "When your child's fever is gone." b. "When all of the lesions have dried up." c. "When the lesions begin to crust over." d. "When all of the lesions are gone."

b. "When all of the lesions have dried up."

The nurse is admitting an adolescent to the surgical unit with a diagnosis of appendicitis. Which question is the most important to ask the parents? a. "Has your child ever had surgery before?" b. "When did your child last eat?" c. "Has your child ever had this type of pain before?" d. "What do you usually give your child for pain relief?"

b. "When did your child last eat?"

A nurse is teaching the parents of a 6-month-old infant about normal growth and development. Which statements regarding infant development are true? Select all that apply. a. A 6-month-old infant has difficulty holding objects b. A 6-month-old infant can usually roll from prone to supine and supine to prone positions c. A teething ring is appropriate for a 6-month-old infant d. Stranger anxiety peaks at age 12 to 18 months e. Head lag is commonly noted in infants at age 6 months f. Lack of visual coordination usually resolves by age 6 months

b. A 6-month-old infant can usually roll from prone to supine and supine to prone positions c. A teething ring is appropriate for a 6-month-old infant f. Lack of visual coordination usually resolves by age 6 months

A 12-year-old client complains of leg pain shortly after being admitted with a fractured tibia sustained in a fall. When the nurse assesses the pain, the client states, "My pain is 7 out of 10." What action by the nurse would be most appropriate? a. Ask the client what makes the pain better. b. Administer pain medication as ordered. c. Provide diversional activities to distract the client. d. Ask the client how the fracture occurred.

b. Administer pain medication as ordered.

A 3-year-old child has been brought to the clinic for assessment because of frequent episodes of constipation. After ruling out an organic cause, the child's plan of care should prioritize: a. Teaching the child's caregivers the need to toilet the child hourly during the day. b. Administering over the counter stool softeners on a temporary basis. c. Teaching the child habits that promote normal bowel function. d. Teaching the child's caregivers how to safely administer an enema.

b. Administering over the counter stool softeners on a temporary basis.

The nurse is evaluating the effectiveness of nutritional therapy for a child with celiac disease. What is the most important assessment? a. Vital signs b. Appearance, size and number of stools c. BUN and serum creatinine level d. Intake and output

b. Appearance, size and number of stools Because celiac disease affects the small intestine, one method to evaluate nutritional therapy is by examining the appearance, size and number of stools for diarrhea, constipation, steatorrhea, or normal stools.

The nurse is to obtain a stool specimen from a 4-year-old child who has a very liquid stool. The child is ambulatory but weak. Which collection method would most effective for the nurse to use? a. Use a tongue blade to scrape a specimen from the diaper. b. Apply a urine bag to the anal area. c. Have the child defecate into a container in the toilet. d. Use a clean bedpan to collect the specimen.

b. Apply a urine bag to the anal area.

The nurse is caring for a child who is in a plaster spica cast. Which is the most therapeutic action for the nurse to take? a. Use a heat lamp to facilitate drying. b. Apply moleskin to the edges of the cast. c. Assist the child with crutch walking after the cast is dry. d. Avoid turning the child until the cast is dry.

b. Apply moleskin to the edges of the cast.

An instructor is developing a plan for a class of nursing students on various skin disorders. When describing urticaria, what would the instructor include? a. It is a type IV hypersensitivity reaction. b. Histamine release leads to vasodilation. c. Wheals appear first followed by erythema. d. The nonpruritic rash blanches with pressure.

b. Histamine release leads to vasodilation.

A mother is concerned that her 3-year-old child has been exposed to erythema infectionsum (Fifth disease) and asks the nurse what symptoms to look for. What is the best response by the nurse? a. A fine erythematous rash with a sandpaper-like texture. b. Intense redness of both cheeks that may spread to the extremities. c. Low-grade fever, followed by vesicular lesions of the trunk, face, and scalp. d. 3 to 5-day history of sustained fever, followed by a diffuse erythematous maculopapular rash.

b. Intense redness of both cheeks that may spread to the extremities.

The nurse is caring for a 29-week-old neonate in the NICU who is prescribed surfactant for respiratory distress. Why is surfactant given in this situation? a. It increases surface tension in the lungs. b. It decreases surface tension in the lungs. c. It acts as a bronchodilator in the lungs. d. It acts as beta-adrenergic for the lungs.

b. It decreases surface tension in the lungs.

The nurse is providing education to a teen who has tinea pedis. What information should be included in the discussion? Select all that apply. a. Rinse feet daily with a solution of equal parts water and hydrogen peroxide. b. Keep feet clean and dry. c. Wear cotton socks. d. Use talcum powder twice daily. e. Apply petroleum jelly to affected areas of feet.

b. Keep feet clean and dry. c. Wear cotton socks.

The nurse is assessing an infant who has just returned to the unit after undergoing a cleft lip repair. The nurse is aware of the potential for trauma to the suture line and determines that which is the best approach? a. Placing mittens on the infant's hands b. Maintaining arm restraints c. Not allowing the parents to touch the touch d. Removing the Logan bar and placing a sterile dressing on the incision

b. Maintaining arm restraints Arm restraints are used to keep the child's arms straight so the child cannot bend their arms and touch or rub the suture line. This could cause damage to the suture line leading to scarring, bleeding, and/or infection.

The nurse notices that an adolescent's temperature over the past 24 hours has risen from 98.8F to 101.6F. The nurse completes a head-to-toe assessment and documents the following nursing note: Temp: 101.6F, Pulse: 88, Resp: 24, BP: 110/60. Lung sounds clear. Harsh cough noted. No sputum. Denies chest pain. Abdomen soft. Positive bowel sounds. Voiding dark amber urine. Last bowel movement this morning. Gait steady with ambulation. No lower extremity edema noted. What would be the nurse's next action? a. Provide this assessment data to the next shift. b. Notify the provider. c. Begin oxygen at 2 L per nasal cannula. d. Obtain a urine culture.

b. Notify the provider. The provider needs to assess the child and diagnostic tests need to be ordered to determine what is causing these symptoms.

A nurse is caring for a 9-year-old in Buck's traction for a fractured femur following an automobile accident. The child complains of increasing pain 1 hour after receiving IV morphine. What is the most appropriate action by the nurse? a. Tell the child that he needs to give the medicine more time to work b. Perform a neurovascular assessment c. Make certain that the weights are hanging freely. d. Administer an oral analgesic now

b. Perform a neurovascular assessment Pain is not expected to increase 1 hour after receiving morphine. Performing a neurovascular assessment is the most appropriate action to determine if the pain is related to a neurovascular problem related to the traction.

A nurse is caring for a child who has Hirschsprung's disease. Which action should the nurse take? a. Encourage a high fiber, low-protein diet. b. Prepare the family for surgery. c. Place an NG tube for decompression. d. Initiate bed rest to conserve energy.

b. Prepare the family for surgery.

The nurse is developing the plan of care for a 3-year-old child with atopic dermatitis. When reviewing the desired patient outcomes, which of the following are common focuses for a child with this diagnosis? Select all that apply. a. Pain management b. Promotion of skin hydration c. Maintenance of skin integrity d. Reduction in anxiety e. Prevention of infection

b. Promotion of skin hydration c. Maintenance of skin integrity e. Prevention of infection

A child presents with a 2-day history of fever, abdominal pain, occasional vomiting, and decreased oral intake. Which finding would the nurse prioritize for immediate reporting to the provider? a. Temperature 101.9oF b. Rebound tenderness and abdominal guarding c. Parents will be leaving the child alone in the hospital d. Child can only tolerate sips of fluid without nausea

b. Rebound tenderness and abdominal guarding

An 11-year-old child diagnosed with muscular dystrophy is hospitalized secondary to a fall. Surgery is necessary as well as skeletal traction. Which complication should be of the greatest concern to the nurse? a. Infection of pin sites b. Respiratory infection c. Redness on skin of the buttocks d. Nonunion healing of the fracture

b. Respiratory infection

A parent asks the nurse what to begin feeding a 6-month-old infant. Which statement is the best response by the nurse? a. Raisins are important to include in the diet to improve fine motor skills. b. Rice cereal is the first solid introduced because it is least allergenic of the cereals. c. Formula is the only source of nutrition given for the first year of an infant's life. d. Introduce honey slowly into the diet to build up the immunity to botulism.

b. Rice cereal is the first solid introduced because it is least allergenic of the cereals.

A 14-year-old child is diagnosed with tinea versicolor. What would the nurse expect the nurse practitioner to order? a. Topical nystatin b. Selenium sulfide c. Diphenhydramine d. Oral griseofulvin

b. Selenium sulfide

The nurse is most concerned when a neonate with esophageal atresia and tracheoesophageal fistula presents with which clinical manifestation? a. Bulging eyeballs b. Sunken anterior fontanelle c. Skin that returns briskly when pinched d. Fluctuating weight gain

b. Sunken anterior fontanelle

A mother of an infant with clubfoot tells the nurse that she feels guilty because she believes that she did something to cause the condition and asks the nurse how this happened to her baby. The nurse should explain that the cause of clubfoot is: a. Due to restricted movement in utero b. Unknown c. Hereditary d. Due to folic acid deficiency

b. Unknown

The nurse is providing teaching on ways to promote skin hydration for the parents of an infant with atopic dermatitis. Which response indicates a need for further teaching? a. "We need to avoid any skin product containing perfumes, dyes or fragrances." b. "We should use a mild soap for sensitive skin." c. "We should bathe our child in hot water twice a day. d. "We should use soap to clean only dirty areas."

c. "We should bathe our child in hot water twice a day.

A 16-year-old diagnosed with tinea pedis questions the nurse about how he may have contracted the condition. What information may be provided to the boy by the nurse? a. "It is unlikely you will be able to determine the cause of the infection." b. "This condition is common in individuals with lowered immunity." c. "You may have gotten the condition from a community shower or gym area." d. "You likely had an infection in another area of your body it has spread."

c. "You may have gotten the condition from a community shower or gym area."

The child has been diagnosed with severe dehydration. The physician has ordered the nurse to administer a bolus of 20 mL/kg of normal saline over a 2 hour period. The child weighs 63.5 pounds. How should the nurse set the child's IV administration pump? a. 7 mL/hr b. 10 mL/hr c. 289 mL/hr d. 577 mL/hr

c. 289 mL/hr

A 1-month-old infant is brought to the pediatrician's office. His mother states that he is fussy and cries as if he is in pain. He is tolerating normal amounts of formula, gaining weight and having episodes of paroxysmal abdominal cramping after feedings. These signs and symptoms indicate that the infant most likely has which condition? a. Intussusception b. Malrotation with volvulus c. Colic d. Pyloric stenosis

c. Colic

The nurse is caring for a child with a Harrington rod instrumentation placement. While assessing the child on the 2nd postop day, the nurse is most concerned with which of the following findings? a. Hypoactive bowel sounds b. Pain along the incision c. Decreased urinary output d. Temp 100.3 degrees F (oral)

c. Decreased urinary output

The nurse is caring for a patient that had a Wilms' tumor removed 6 hours ago. What assessment finding requires the most immediate action by the nurse? a. Bowel sounds are absent. b. Pain rating on the FLACC scale increased from 2 to 5. c. Lung sounds with wheezes throughout. d. Abdominal incision with a dime-sized drop of dried blood.

c. Lung sounds with wheezes throughout.

A nurse is caring for a newborn whose chest x-ray reveals marked hyperaeration mixed with areas of atelectasis. The infant's arterial blood gas analysis indicates metabolic acidosis. The nurse should prepare for the assessment of which of the following dangerous conditions? a. Chonanal atresia b. NEC c. Meconium aspiration d. Hyperbilirubinemia

c. Meconium aspiration

The nurse is caring for a 13-year-old girl with acne vulgaris and is teaching the girl about skin care. Which response by the girl indicates a need for further teaching? a. "I must use my medicine daily so that it will work." b. "I should use a humectant moisturizer." c. "It is best to avoid hats and headbands." d. "I should avoid eating any kind of chocolate."

d. "I should avoid eating any kind of chocolate."

The nurse is caring for a 4-year-old boy who has undergone an appendectomy. The child is unwilling to use the incentive spirometer. Which approach would be most appropriate to prevent postop respiratory complications? a. "Can you please cough like a big boy?" b. "Blow the light out on my penlight while we wait for your mom." c. "Until you blow in this bubble wand, you can't go to the playroom." d. "Let's play blow the cotton ball across the table." e. "Blow in this Power Ranger bad-guy zapper gun."

d. "Let's play blow the cotton ball across the table."

A nurse is caring for a toddler who is diagnosed with hip dysplasia and has been placed in a hip spica cast. The child's mother asks the nurse why a Pavlik harness is not being used. Which of the following responses by the nurse appropriately addresses the mother's question? a. "The Pavlik harness cannot be used for your child because her condition is too severe." b. "The Pavlik harness is used for children with scoliosis, not hip dysplasia." c. "The Pavlik harness is used for school-age children." d. "The Pavlik harness is used for infants less than 6 months of age."

d. "The Pavlik harness is used for infants less than 6 months of age."

A child in the preschool classroom has been diagnosed with scarlet fever. Several parents have called the school and voiced concern over the risk of their children becoming infected. The parents are requesting that the infected child be isolated for one month. It is most appropriate for the nurse to tell the parents that respiratory isolation of an infected child is necessary until: a. the associated rash disappears. b. completion of antibiotic therapy. c. the child is fever-free for 24 hours. d. 24 hours after initiation of treatment.

d. 24 hours after initiation of treatment.

The infant is listless with sunken fontanels and has been diagnosed with hypotonic dehydration. The infant is still producing at least 1 mL/kg each hour of urine. The infant weighs 13.2 pounds. At the minimum, how many milliliters of urine will the infant produce during the next 8-hour shift? a. 6 mL b. 8 mL c. 36 mL d. 48 mL

d. 48 mL

A nurse just received a report from the nurse who worked the previous shift. Which child should be assessed first? a. A 5-year-old child who needs factor VII before correction of scoliosis. b. A 4-year-old child admitted with asthma receiving albuterol every 4 hours. c. A 3-year-old child who had an appendectomy and is complaining of pain. d. A 6-year-old child with ventricular septal defect on 2 liters of oxygen.

d. A 6-year-old child with ventricular septal defect on 2 liters of oxygen.

An infant is examined and found to have petechial rash. The nurse documents the rash as a. A purple macular lesion larger than 1 cm in diameter. b. Purple to brown bruises, macular or popular, of various sizes. c. A collection of blood from ruptured blood vessels larger than 1 cm in diameter. d. A pinpoint, pink to purple, nonblanching macular lesion 1 to 3 mm in diameter.

d. A pinpoint, pink to purple, nonblanching macular lesion 1 to 3 mm in diameter.

The nurse instructs the parent of a child with a hip spica cast to avoid gas-forming foods. The parent asks the nurse what can happen if the food is consumed. What is the best response by the nurse? a. Diarrhea b. Flatus c. Constipation d. Abdominal distention

d. Abdominal distention

A child has just returned to his room with a cast on his leg after open reduction of a fractured femur. The nurse assesses the child and notes a 4 cm by 6 cm area of blood on the cast. What is the most important action for the nurse to take? a. Tape gauze pads over the bloody area b. Call the health care provider c. Mark the bloody drainage and monitor hourly d. Assess vital signs

d. Assess vital signs

On assessment of a child's skin, the nurse notes a papular, pruritic rash with some vesicles. The rash is profuse on the trunk and sparse on the distal limbs. Based on the assessment, which illness does the child have? a. Measles b. Mumps c. Roseola d. Chickenpox

d. Chickenpox

The nurse is caring for a child with cerebral palsy who requires a wheelchair to attain mobility. Which intervention would help the child achieve a sense of normality? a. Encourage follow-through with physical therapy exercises. b. Restrict the child to a special needs classroom. c. Encourage after-school activities within the limits of the child's abilities. d. Ensure the school is aware of the child's capabilities.

d. Ensure the school is aware of the child's capabilities. This question deals with mobility in a wheelchair and achieving the highest level of functioning and autonomy. It is most important for the school personnel to understand what the child is capable of so that they can allow the child to function accordingly. Options A & C are important but not the most important. Option B is not necessary unless the parents and child desire that.

The nurse is assessing the stool of a child with celiac disease. How would the nurse expect the stool to appear? a. Constipated, hard stool b. Green, starvation-type stool c. Red, currant jelly stool d. Foul-smelling, fatty stool

d. Foul-smelling, fatty stool Children with celiac disease often have foul-smelling, fatty stools. Even when they exhibit constipation, the stools tend to be fatty. They exhibit constipation by having fewer stools than normal, but not necessarily hard. Green, starvation-type stools are usually seen when a child is having frequent episodes of diarrhea and just consuming liquids. Red, currant jelly stools are characteristic of intussusception.

The nurse recognizes that the parent of a child with developmental hip dysplasia needs additional teaching when the parent places the child in a position that encourages: a. Hip abduction b. External rotation c. Knee extension d. Internal rotation

d. Internal rotation

During a scoliosis screening, a school nurse notices a raised iliac crest height. The nurse should suspect which condition? a. Increased thoracic kyphosis b. Increased lumbar lordosis c. Forward head posture d. Leg length discrepancy

d. Leg length discrepancy

The nurse would expect the physician to order which medication as the treatment of choice for scarlet fever? a. Acyclovir b. Amphotericin B c. Ibuprofen d. Penicillin

d. Penicillin

Which of the following diagnostic procedure should the nurse prepare the child for to determine if the child has Legg-Calve-Perthes disease? a. Bone biopsy b. Genetic testing c. Bone aspiration d. Radiographs

d. Radiographs

Which instruction should the nurse include in the teaching plan for the parent of a 10-year-old child with a fracture of the radial bone? a. Report capillary refill less than 3 seconds b. Report fingers that feel different from the unaffected fingers c. Report warmth under the cast during the first 24 hours after application d. Report foul odors coming from the cast

d. Report foul odors coming from the cas

The nurse suspects an infant may have a tracheoesophageal fistula or esophageal atresia. What is the most important intervention for the nurse to implement? a. Administer oxygen b. Tell the parents c. Put the infant in an Isolette or on a radiant warmer d. Report the suspicion to the physician

d. Report the suspicion to the physician Reporting suspicions of tracheoesophageal fistula or esophageal atresia to the provider is most important because many of these infants having difficulty breathing that progresses rapidly to respiratory distress.

A parent asks the nurse if it is alright to let his child scratch the chickenpox on his abdomen. The nurse explains that if the child scratches the chickenpox, he may be at risk for developing which condition? a. Myocarditiis b. Neuritis c. Obstructive laryngitis d. Secondary bacterial infection

d. Secondary bacterial infection