NCLEX child health: Cardio and respiratory

A child with rheumatic fever will be arriving to the nursing unit for admission. On admission assessment, the nurse should ask the parents which question to elicit assessment information specific to the development of rheumatic fever?

Did the child have a sore throat or fever within the last 2 months?"

The nurse is caring for a child after a tonsillectomy. The nurse monitors the child, knowing that which finding indicates the child is bleeding?

Frequent swallowing

A pediatric nurse in the ambulatory surgery unit is caring for a child following a tonsillectomy. The child is complaining of a dry throat. Which item should the nurse offer to the child?

Green gelatin

The nurse is collecting data on a child with a diagnosis of rheumatic fever. Which question should the nurse initially ask the mother of the child?

Has the child complained of a sore throat within the past few months?

The nurse is creating a plan of care for a child admitted with a diagnosis of Kawasaki disease. In developing the initial plan of care, the nurse should include monitoring the child for signs of which condition?

Heart failure

The nurse is providing instructions to the mother of a child with croup regarding treatment measures if an acute spasmodic episode occurs. Which statement made by the mother indicates a need for further teaching?

I should place a steam vaporizer in my child's room."

Breathing exercises and postural drainage are prescribed for a hospitalized child with cystic fibrosis. What instruction should the nurse include in the client's teaching plan?

Perform the postural drainage first and then the breathing exercises.

The nurse in the ambulatory care unit is caring for a child after a tonsillectomy. The child's mother tells the nurse that the child is complaining of a dry throat and would like something to relieve the dryness. Which item should the nurse provide for the mother to give to the child?

Yellow noncitrus Jell-O

A 1-year-old infant with a diagnosis of heart failure is prescribed digoxin. The nurse takes the apical pulse for 1 minute before administering the medication and obtains a result of 102 beats/minute. What is the nurse's best action

Administer the medication.

The nurse is closely monitoring the intake and output of an infant with heart failure who is receiving diuretic therapy. The nurse should use which most appropriate method to assess the urine output?

Weighing the diapers

The mother of a hospitalized 2-year-old child with viral laryngotracheobronchitis (croup) asks the nurse why the health care provider did not prescribe antibiotics. Which response should the nurse make?

"Antibiotics are not indicated unless a bacterial infection is present."

A child is scheduled for a tonsillectomy in a day surgical unit. On the day after surgery, the mother calls the surgical unit and expresses concern because the child has a bad mouth odor. Which response is most appropriate?

"Bad mouth odor is normal and may be relieved by drinking more liquids."

The nurse has provided home care instructions to the parents of a child who is being discharged after cardiac surgery. Which statement made by the parents indicates a need for further instruction?

"I can apply lotion or powder to the incision if it is itchy."

The nurse is reviewing the laboratory results for a child scheduled for a tonsillectomy. The nurse determines that which laboratory value is most significant to review?

Prothrombin time

After a tonsillectomy, the nurse reviews the health care provider's (HCP's) postoperative prescriptions. Which prescription should the nurse question

Suction every 2 hours.

The nurse provides home care instructions to the parents of a child with heart failure regarding the procedure for administration of digoxin. Which statement made by the parent indicates the need for further instruction?

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

The nurse has provided instructions to the mother of a child with cystic fibrosis about appropriate dietary measures. Which statement by the mother indicates an understanding of these dietary measures?

"The diet needs to be high in calories."

A child is being discharged from the hospital following heart surgery. Prior to discharge, the nurse reviews the discharge instructions with the mother. Which statement by the mother indicates a need for further teaching?

"Visitors are not allowed for 1 month."

The mother of a child with cystic fibrosis (CF) asks the clinic nurse about the disease. What should the nurse tell the mother about CF?

A chronic multisystem disorder affecting the exocrine glands

The nurse employed in an emergency department is monitoring a child diagnosed with epiglottitis. The nurse notes that the child is leaning forward with the chin thrust out. How should the nurse interpret this finding?

An airway obstruction

The nurse reviews the laboratory results for a child with a suspected diagnosis of rheumatic fever, knowing that which laboratory study would assist in confirming the diagnosis?

Anti-streptolysin O titer

A new parent expresses concern to the nurse regarding sudden infant death syndrome (SIDS). She asks the nurse how to position her new infant for sleep. In which position should the nurse tell the parent to place the infant?

Back rather than on the stomach

The nurse is caring for a child with a diagnosis of a right-to-left cardiac shunt. On review of the child's record, the nurse should expect to note documentation of which most common assessment finding?

Bluish discoloration of the skin

The nurse is caring for an infant with a diagnosis of congenital heart disease. Which finding, on physical assessment, does the nurse attribute to chronic hypoxia?

Clubbing of the fingers

On assessment of a child admitted with a diagnosis of acute-stage Kawasaki disease, the nurse expects to note which clinical manifestation of the acute stage of the disease?

Conjunctival hyperemia

The nurse is reviewing the health care provider's prescriptions for a child with rheumatic fever who is suspected of having a viral infection. The nurse notes that aspirin is prescribed for the child. Which nursing action is most appropriate?

Consult with the health care provider to verify the prescription.

A 10-year-old child with asthma is treated for acute exacerbation in the emergency department. The nurse caring for the child should monitor for which sign, knowing that it indicates a worsening of the condition?

Decreased wheezing

The nurse is caring for an infant with congenital heart disease. Which, if noted in the infant, should alert the nurse to the early development of heart failure?

Diaphoresis during feeding

The nurse reviews the laboratory results for a child with rheumatic fever and would expect to note which findings? Select all that apply.

Elevated C-reactive protein Elevated antistreptolysin O titer Decreased erythrocyte sedimentation rate Presence of group A beta-hemolytic strep

A child has been tentatively diagnosed with rheumatic fever. The nurse interprets that this diagnosis is consistent with which laboratory result obtained for this child?

Elevated antistreptolysin O titer

A 12-year-old is admitted to the hospital with a low-grade fever and joint pain. Which diagnostic test finding will assist to determine a diagnosis of rheumatic fever?

Elevated erythrocyte sedimentation rate

The mother of an 8-year-old child being treated for right lower lobe pneumonia at home calls the clinic nurse. The mother tells the nurse that the child complains of discomfort on the right side and that ibuprofen is not effective. Which instruction should the nurse provide to the mother?

Encourage the child to lie on the right side.

The clinic nurse reviews the record of a child just seen by a health care provider and diagnosed with suspected aortic stenosis. The nurse expects to note documentation of which clinical manifestation specifically found in this disorder

Exercise intolerance

A mother calls the health care provider's office requesting an appointment for her 8-year-old child. She states he has asthma and is telling her he had trouble breathing last night and does not want to go to school. In triaging this child, which is the most important question to initially ask the mother?

Is your child telling you at this time he is having trouble breathing?"

The nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic, and the nurse recognizes that the infant is experiencing a hypercyanotic spell (blue or tet spell). The nurse immediately places the infant in what position?

Knee-chest position

A child with laryngotracheobronchitis (croup) is placed in a cool mist tent. The mother becomes concerned because the child is frightened, consistently crying and trying to climb out of the tent. Which is the most appropriate nursing action?

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

Assessment findings of an infant admitted to the hospital reveal a machinery-like murmur on auscultation of the heart and signs of heart failure. The nurse reviews congenital cardiac anomalies and identifies the infant's condition as which disorder? Refer to the figure (circled area) to determine the condition.

Patent ductus arteriosus

The student nurse is caring for an infant with a tracheostomy and is preparing to suction the infant. The nursing instructor should intervene if the nursing student stated she would take which action to perform this procedure?

Limit insertion and suctioning time to 15 seconds to prevent hypoxia

Prostaglandin E1 is prescribed for a child with transposition of the great arteries. The mother of the child is a registered nurse and asks the nurse why the child needs the medication. What is the most appropriate response to the mother about the action of the medication?

Maintains adequate cardiac output

The nurse is caring for an infant with bronchiolitis, and diagnostic tests have confirmed respiratory syncytial virus (RSV). On the basis of this finding, which is the most appropriate nursing action?

Move the infant to a room with another child with RSV.

The nurse reviews the health record of a 2-year-old child. The health care provider has documented that the results of a tuberculin skin test have indicated an area of induration measuring 5 mm. How should the nurse interpret these results?

Negative

A mother arrives at the hospital emergency department with her child, in whom a diagnosis of epiglottitis is documented. Which prescription, if written by the health care provider, should the nurse question?

Obtain a throat culture.

A nursing student is conducting a clinical conference about measures that assist in preventing sudden infant death syndrome. The student plans to write on a handout that it is best to place an infant in which position for sleep?

On the back, or supine

The nurse is assigned to care for an infant with tetralogy of Fallot. The mother of the infant calls the nurse to the room because the infant suddenly seems to be having difficulty breathing. The nurse enters the room and notes that the infant is experiencing a hypercyanotic episode. What is the priority action by the nurse?

Place the infant in a knee-chest position.

The nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by respiratory syncytial virus (RSV). Which interventions should the nurse include in the plan of care? Select all that apply.

Place the infant in a private room Ensure that nurses caring for the infant with RSV do not care for other high-risk children.

The clinic nurse reads the results of a tuberculin skin test (TST) on a 3-year-old child. The results indicate an area of induration measuring 10 mm. The nurse should interpret these results as which finding?

Positive

A child is scheduled for a tonsillectomy. The nurse plans care, knowing that which condition would be a priority because it presents the highest risk of aspiration during surgery?

Presence of loose teeth

After a tonsillectomy, a child is brought to the pediatric unit. The nurse should appropriately place the child in which position?

Prone

The nurse is preparing to care for a child after a tonsillectomy. The nurse documents on the plan of care to place the child in which position?

Side-lying

The nurse is reviewing the health care provider's prescriptions for a child following a tonsillectomy. Which prescription should the nurse question?

Suction the child frequently if coughing.

The nurse is caring for a child following a tonsillectomy. The nurse should reposition the child on return from the operating room if the child is in which position?

Supine

A mother arrives at the clinic with her 3-year-old child. The mother tells the nurse that the child has had a fever and a cough for the past 2 days and that this morning the child began to wheeze. Viral pneumonia is diagnosed. Based on the diagnosis, the nurse anticipates that which will be a component of the treatment plan?

Supportive treatment

The nurse is monitoring an infant with congenital heart disease closely for signs of heart failure (HF). The nurse should assess the infant for which early sign of HF?

Tachycardia

The emergency department nurse is caring for a child diagnosed with epiglottitis. In assessing the child, the nurse should monitor for which indication that the child may be experiencing airway obstruction?

The child is leaning forward, with the chin thrust out.

The mother of a child being discharged after heart surgery asks the nurse when the child will be able to return to school. Which is the most appropriate response to the mother?

The child may return to school in 3 weeks but needs to go half-days for the first few days."

During clinical conference, a nursing student is discussing care for a child with a diagnosis of cystic fibrosis (CF). Which comment by a student indicates the need for further review of information about CF?

This disease causes dilation of the passageways of many organs.

After a tonsillectomy, a child begins to vomit bright red blood. The nurse should take which initial action?

Turn the child to the side.

A health care provider has prescribed oxygen as needed for an infant with heart failure. In which situation should the nurse administer the oxygen to the infant?

hen drawing blood for electrolyte level testing

The nurse is assessing a newborn with heart failure before administering the prescribed digoxin. In reviewing the laboratory data, the nurse notes that the newborn has a digoxin blood level of 1.6 ng/mL (2.05 mmol/L) and an apical heart rate of 90 beats/min. The mother also tells the nurse that the newborn just vomited her formula. Which intervention should the nurse take?

withhold the medication and notify the health care provider.

An ambulatory care nurse is preparing a list of instructions for the parents of a child who is being discharged after a tonsillectomy. The nurse should place which instructions on the list? Select all that apply.

Avoid hot fluids. Avoid raw vegetables. Rest in bed or on a couch for 24 hours.

The nurse is caring for a hospitalized infant with a diagnosis of bronchiolitis. In which position should the nurse place the infant?

Head and chest at a 30-degree angle with the neck slightly extended

A child with a diagnosis of tetralogy of Fallot exhibits an increased depth and rate of respirations. On further assessment, the nurse notes increased hypoxemia. The nurse interprets these findings as indicating which situation?

A hypercyanotic episode

The nurse is monitoring an infant with heart failure. Which sign alerts the nurse to suspect fluid accumulation and the need to call the health care provider?

A weight gain of 1 lb (0.5 kg) in 1 day

A school nurse is teaching parents about emergency treatment for epistaxis. Which best action should the nurse take to assist the parents in understanding the emergency treatment?

Ask the parents to demonstrate, on a mannequin, where to apply continuous pressure if a nosebleed occurs.

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

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

The nurse is preparing to administer digoxin to an infant with heart failure. Before administering the medication, the nurse double-checks the dose, counts the apical heart rate for 1 full minute, and obtains a rate of 80 beats/minute. Based on this finding, which is the appropriate nursing action?

Withhold the medication.