Pediatrics: Nursing Care of Children Final
A nurse is preparing to administer diphenhydramine 5mg/kg/day PO to divide equally every 8 hr to school-age child whoweighs50 Ib. Available is diphenhydramine oral solution 12.5 mg/5mL. How many mL should the nurse administer per dose? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
15mL
A nurse is preparing to administer acetaminophen 240 mg PO daily to a child who has a temperature of 38.9C (102F). The amount available is acetaminophen oral solution 160 mg/5 mL. How many ml should the nurse administer per dose? ( Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.)
7.5mL
A nurse is teaching the parents of a 4-month-old infant who has gastroesophageal reflux. Which of the following statements by the parents indicates an understanding of the teaching? A. "I will add 1 teaspoon of rice cereal per ounce to my baby's formula." B. "I will place my baby on her side when sleeping."- The American Academy of Pediatrics recommends supine sleeping for infants. Infants who have gastroesophageal reflux should be placed in a supine position with the head elevated. C. "I will decrease the number of feedings my baby receives per day." - Decreasing the number of feedings per day is contraindicated. An infant must eat to gain nutrients and caloric intake important for growth and development. D. "I will give my baby loperamide with each feeding." - Loperamide is an antidiarrheal medication that is contraindicated for children less than 2 years of age. An infant who has gastroesophageal reflux can benefit from an H2 receptor antagonist or proton pump inhibitor.
A. "I will add 1 teaspoon of rice cereal per ounce to my baby's formula." - The parents can give the infant thickened feedings with rice cereal to help decrease the reflux. In addition, the added calories can help those infants who are underweight due to the gastroesophageal reflux.
A nurse at a clinic is preparing to administer immunizations to a 5-year-old child. Which of the following immunizations should the nurse plan to give? A. Diphtheria, tetanus, and pertussis (DTaP) B. Pneumococcal (PCV) - The infant should receive the PCV immunization at 2 months, 4 months, and 6 months, and the fourth dose between 12 to 18 months. C. Haemophilus influenza type B (Hib) - The infant should receive the Hib immunization at 2 months, 4 months, and 6 months, and the fourth dose between 12 to 18 months. D. Hepatitis B (Hep B) - The infant should receive the Hep B immunization at birth, 1 to 2 months, and the third dose at 6 to 18 months.
A. Diphtheria, tetanus, and pertussis (DTaP) - Children should receive booster doses of the DTaP immunization between the ages of 4 and 6. It is around this age that blood titers drop due to decreasing antibodies.
A nurse is planning care for a preschool-age child who has autism and is being admitted to the facility. Which of the following actions should the nurse plan to take? A. Encourage the parents to bring in the child's stuffed animal. B. Give the child choices when planning daily activities. - Children who have autism have difficulty organizing behaviors; therefore, it is best to not give choices. C. Administer phenytoin three times per day. - Phenytoin is taken by children who have seizure disorders. D. Provide a shared room with another child his age. - Children who have autism need decreasing stimulation and avoidance of auditory or visual distraction. These children should have a private room.
A. Encourage the parents to bring in the child's stuffed animal. - Encouraging parents to bring in a child's favorite stuffed animal helps lessen the disruptiveness of hospitalization.
A nurse is caring for a 2-day-old infant who has a myelomeningocele. Which of the following actions should the nurse take? A. Monitor the infant's head circumference. B. Position the infant supine. - The nurse should place an infant who has myelomeningocele in a prone position to minimize risk of trauma or tension to the sac. C. Place the infant under a radiant warmer. - The nurse should not place an infant who has myelomeningocele under a radiant warmer, because of the risk of drying out the lesion and causing cracking. D. Tape a piece of plastic over the protruding membranes. - Placing a piece of plastic over the protruding membranes will exert pressure on the area. The nurse can place wet gauze over the lesion to help provide moisture.
A. Monitor the infant's head circumference. - Infants who have myelomeningocele have an increased risk for hydrocephalus. Measuring the infant's head circumference helps to determine any increase.
A nurse is preparing a school-age child for a tonsillectomy. Which of the following actions should the nurse take? A. Schedule the child for a preoperative visit to the facility. - After 9 years of age, a child understands concepts of death. The nurse should inform the child that he is taking a "special sleep" not that he is being "put to sleep". Children who have pets might refer to being "put to sleep" as death. B. Inform the child he will be put to sleep during the procedure. - C. Read the child a story about a cartoon character having a similar operation. - Reading a cartoon book is developmentally appropriate for a preschool-age child or toddler. Participating in therapeutic play has benefits for those age groups. D. Tell the child the appointment is to have his throat checked. - Children need factual information and explanations about what will happen during hospitalizations.
A. Schedule the child for a preoperative visit to the facility. - A preoperative visit to the facility allows the child to observe perioperative processes. This education helps the child feel at ease prior to the surgical procedure.
A nurse is caring for a 2-year-old child who has frequent highlight urinary tract infections. When educating the parents about the prevention of urinary tract infections, Which of the following instructions should the nurse include in the teaching? A. Teach the child to wipe from front to back. B. Give the child frequent bubble baths. - The child should avoid bubble baths, because they can cause urethral irritation. C. Urge the child to urinate every 6 hr. - The child should urinate at least every 4 hr to prevent stasis of the urine in the bladder, because stasis urine can cause bacteria growth. D. Administer oxybutynin daily.- Oxybutynin is an antispasmodic used for clients ages 6 and older who have neurogenic bladders.
A. Teach the child to wipe from front to back. - The child should be taught to wipe from front to back because this prevents bacterial contamination from the anal area entering the urethra.
A nurse is caring for a group of infants who have congenital heart defects. For which of the following defects should the nurse expect to observe cyanosis? A. Transposition of great arteries B. Ventricular-septal defect - An infant who has a ventricular-septal defect, a hole in the septal wall between the ventricles, can have increased pulmonary vascular resistance but is unlikely to have cyanosis because oxygenation of the blood remains adequate for the systemic circulation. C. Coarctation of the aorta - An infant who has coarctation of the aorta, a constricted segment of the aorta that obstructs blood flow to the body, is unlikely to have cyanosis because even though the left ventricle must generate higher than normal pressures for adequate stroke volume, oxygenation of the blood remains adequate for the systemic circulation. D. Patent-ductus arteriosus - An infant who has a patent-ductus arteriosus will have a blood vessel connecting the pulmonary artery to the aorta. The infant can have increased pulmonary vascular resistance, but oxygenation of the blood remains adequate for the systemic circulation.
A. Transposition of great arteries - An infant who has transposition of great arteries will have severe cyanosis because reversal of the anatomic position of the aorta and pulmonary artery allows venous blood to enter the systemic circulation without oxygenation.
A nurse is preparing to administer an intramuscular injection to a 2-month-old infant. In which of the following sites should the nurse plan to administer the injection? A. Vastus lateralis B. Dorsogluteal- Receiving an injection at the dorsogluteal site at 2 months of age is contraindicated because the muscle is pooly developed. C. Deltoid - The deltoid has a small muscle mass, and the proximity of the radial and axillary nerves make it suitable for use only after the age of 18 months. D. Abdomen 5 cm (2 in) from the umbilicus - The abdomen is a site used for subcutaneous injections.
A. Vastus lateralis - The vastus lateralis is a large, developed muscle, even in an infant. The muscle can tolerate the volume of the injection, and there are no important nerves or blood vessels in this muscle.
A nurse is teaching parents of a 10-year-old child who has iron-deficiency anemia. Which of the following statements by a parent indicates an understandings of the teaching? A. "I will give my child an iron tablet once each day at bedtime." - The parent should spread the iron doses throughout the day to prevent gastric upset. B. "I will administer the iron tablet with orange juice." C. "I will encourage my child to take an antacid with the iron tablet."- Antacids decrease the absorption of iron. D. "I will crush the iron tablet prior to giving it to my child." - Crushing the tablet interferes with its absorption and distribution.
B. "I will administer the iron tablet with orange juice." - The intake of citrus juices with the iron will increase the iron's absorption.
A nurse is teaching the parent of a 3-year-old child who has persistent otitis media about prevention. Which of the following statements by the parents indicates an understanding of the teaching? A. "My child should not play around others who have ear infections." - A child who has an ear infection is not contagious; therefore, the child may play with other children who have ear infections. B. "We should not smoke around our child." C. "My child should not swim this summer." - A child who has recurrent ear infections is able to swim; however, wearing earplugs might aid in decreasing the risk of infection. D. "I will encourage my child to blow his nose forcefully when he has a cold." - A child who has recurrent ear infections should not forcefully blow his nose during a cold, because this causes organisms to ascend through the eustachian tubes.
B. "We should not smoke around our child." - Preventing exposure to tobacco smoke at home can prevent further episodes of ear infections because tobacco smoke can cause inflammation of the respiratory tract.
A nurse is caring for a 10-year-old child who should reduce his fat intake. Which of the following menu choices should the nurse suggest? A. A hot dog on a whole wheat bun - A hot dog on a bun contains more than 18.1 g of fat. B. 3 oz of baked chicken on a whole wheat roll C. 1/2 cup diced potatoes with scrambled eggs - Diced potatoes with scrambled eggs contain 16.5 g of fat. D. A medium blueberry muffin - A medium blueberry muffin contains 18.2 g of fat.
B. 3 oz of baked chicken on a whole wheat roll - A baked chicken sandwich on a whole wheat bun has the lowest fat content at 6.2 g.
A nurse is caring for a child who is in the emergency department after ingesting a bottle of acetaminophen. Which of the following medications should the nurse plan to administer? A. Digoxin immune fab - Digoxin immune fab is an antidote for digoxin toxicity. B. Acetylcysteine C. Naloxone - Naloxone is the antidote for opioid overdose. D. Vitamin K - Children who have salicylate, or aspirin, poisoning or overdose should receive vitamin K to decrease bleeding.
B. Acetylcysteine - Acetylcysteine is the antidote for acetaminophen overdose or poisoning.
A nurse is caring for a 4-year-old child who has pneumonia. The child's mother left 2 hr ago and he is currently experiencing the separation anxiety stages of despair. Which of the following findings should the nurse expect? A. Crying and screaming - The protest stage is the first stage seen in separation anxiety, which includes the child crying and screaming. B. Inactive and thumb sucking C. Shows interest in toys around him - Denial, or detachment, is the third stage of separation anxiety, in which the child appears happy and interacts with strangers. D. Attempts to escape and find parent - The protest stage is the first stage seen in separation anxiety, which includes the child attempting to escape the area to find a parent.
B. Inactive and thumb sucking - A child who is sucking his thumb and refusing to eat or drink is displaying manifestations of the second stage of separation anxiety, which is despair.
A nurse is caring for a preschool-age child who has mucosal ulceration after receiving chemotherapy. Which of the following actions should the nurse take? A. Place viscous lidocaine on the child's oral lesions. - Preschool-age children should not take viscous lidocaine, because it depresses the gag reflex, increasing their risk of aspiration. B. Instruct the child to use a soft sponge toothbrush when brushing her teeth. C. Encourage the child to mouth rinse with hydrogen peroxide every 2 to 4 hr. - Children who have mucosal ulcers should not use hydrogen peroxide as a mouth rinse, because it causes drying effects of the mucosa and might cause further ulceration. D. Give the child lemon glycerin swabs to use after each meal. - Children who have mucosal ulcerations should avoid the use of lemon glycerin swabs because they are very irritating, especially on eroded tissues.
B. Instruct the child to use a soft sponge toothbrush when brushing her teeth. - The child should use a soft sponge toothbrush when brushing her teeth because a regular toothbrush might cause further irritation to the mucosal ulcers.
A school nurse is assessing a child who has been stung by a bee. The child's hand is swelling and the nurse notes that the child has allergies to insect stings. Which of the following findings should the nurse expect if the child develops anaphylaxis? (Select all that apply.) A. Bradycardia - Histamine is a potent vasodilator; therefore, the client who is going into anaphylaxis will exhibit tachycardia. B. Nausea C. Hypertension - Histamine is a potent vasodilator and the child will exhibit hypotension. D. Urticaria E. Stridor
B. Nausea - A common gastrointestinal response to excessive histamine release is nausea. D. Urticaria - A common skin manifestation of excessive histamine release is hives, also known as urticaria. E. Stridor - A serious, life-threatening response to excessive histamine release is airway narrowing, which presents as dyspnea and stridor.
A nurse is providing postoperative teaching for the parent of a 3-month-old infant who is recovering from umbilical hernia repair. Which of the following statements by the parents indicates an understanding of the teaching? A. "I will expect the site to bulge when my baby cries." - Crying can increase intra-abdominal pressure; however, this does not result in bulging at the site. B. "I will place a belly band around my child's abdomen." - The parent should not use a belly band, because they can lead to bowel strangulation. C. "I will fold my baby's diaper away from the incision." D. "I will bathe my child in the bath tub daily." - The parent should sponge bathe the infant until the postoperative visit when the provider removes the dressing.
C. "I will fold my baby's diaper away from the incision." - To prevent infection, the parent should be able to verbalize and demonstrate proper folding of the diaper to protect the surgical incision from contamination.
A nurse is teaching a school-age child who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements should the nurse make? A. "If you take too much insulin, drink a sugar-free cola."- Sugar-free cola will not increase the blood sugar, because it does not contain sugar. Encourage the child to drink juice or milk and eat a complex carbohydrate. B. "You will need to decrease your insulin dosage when you become a teenager." - Insulin requirements increase during puberty due to a decreased sensitivity to insulin, resulting in an increase in the child's insulin dosage. C. "You can use a vial of insulin for up to 30 days." D. "Stop taking your insulin if you are vomiting." - Blood glucose levels rise during times of illness and stress; therefore, the child might need to contact the provider for an increased insulin dosage.
C. "You can use a vial of insulin for up to 30 days." - The child can use an opened vial of insulin for 28 to 30 days stored at room temperature or in the refrigerator.
A nurse is teaching the parents of a child who has cerebral palsy. Which of the following statements should the nurse make? A. "Your child will be unable to eat by mouth." - Children who have cerebral palsy may eat food by mouth; however, the parents might need to use special feeding techniques. B. "Your child will be unable to participate in recreational activities." - Children who have cerebral palsy are able to participate in recreational activities. Some facilities have specific activities for those children who have disabilities. C. "Your child will need a botulinum toxin A injection to help with muscle spasticity." D. "Your child will need throw rugs placed over non-carpeted areas." - The parents should not use throw rugs, because children who have cerebral palsy have an increased risk of falls.
C. "Your child will need a botulinum toxin A injection to help with muscle spasticity." - Children who have cerebral palsy have spasticity in their muscles. The child can receive botulinum toxin type A injections into affected muscles, which aid in reducing the spasticity.
A nurse is caring for a child who has epistaxis. Which of the following actions should the nurse take? A. Apply a warm cloth to the bridge of the child's nose. - Applying a warm cloth to the bridge of the nose causes vasodilation, which can increase the bleeding. B. Tilt the child's head back. - Tilting the head back allows blood to flow down the back of the throat, which can cause nausea. C. Apply continuous pressure to the child's nose for at least 10 min. D. Administer aspirin for the child's pain. - Aspirin can increase bleeding from the site due to its antithrombotic actions. The use of aspirin is contraindicated in children.
C. Apply continuous pressure to the child's nose for at least 10 min. - The nurse needs to apply continuous pressure for at least 10 minutes to help stop bleeding.
A nurse is caring for a 4-month-old child who has acute otitis media and a fever of 38.3C (101F). Which of the following medications should the nurse administer? A. Diphenhydramine - Diphenhydramine is an antihistamine used for allergic reactions. B. Furosemide - Furosemide is a diuretic used to decrease edema. C. Amoxicillin D. Ibuprofen - Children less than 6 months old should not take ibuprofen. Acetaminophen is the preferred choice for children of this age.
C. Amoxicillin - A child who has acute otitis media should take an antibiotic to help alleviate the infection.
A nurse on the pediatric unit is caring for a group of clients. Which of the following findings should be the nurse's priority? A. A child who has asthma and a pulse oximetry of 94% - A child who has asthma should have a pulse oximetry reading of 90% or greater; therefore, this is not the nurse's priority finding. B. A child who has nephrotic syndrome and 1+ protein on the urine dipstick - The child who has nephrotic syndrome typically has moderate to large amounts of protein in the urine; therefore, this is not the nurse's priority finding. C. A child who has sickle cell anemia and a urine specific gravity of 1.030 D. A child who has insulin-dependent diabetes mellitus and a fingerstick glucose reading of 110 mg/dL - A blood glucose level of 110 mg/dL is within the expected reference range; therefore, this is not the nurse's priority.
C. A child who has sickle cell anemia and a urine specific gravity of 1.030 - The nurse should apply the ABC priority-setting framework. This framework emphasizes the basic core of human functioning - having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life, and is therefore the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second-highest priority in the ABC priority-setting framework because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority in the ABC priority setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. A child who has sickle cell anemia must maintain adequate hydration because dehydration might cause sickle cell crisis that can occlude the child's circulation.
A nurse is caring for a toddler who has asthma. The parents are concerned about the toddler's reaction to the hospitalization. Which of the following actions should the nurse take to decrease the child's anxiety? A. Provide privacy. - Toddlers are not as concerned about privacy as school-age children and adolescents. These children prefer to be with someone during procedures. B. Give the child a thorough explanation before providing care. - A nurse should provide a toddler with short, simple explanations. A long explanation might cause heightened anxiety in the child. C. Encourage rooming-in. D. Tell the child you will help fix her. - When the nurse is speaking to a toddler, she should refrain from using the word "fix" because toddlers assume they are broken. Instead, the nurse should say, "I will help make you feel better."
C. Encourage rooming-in. - Rooming-in is the most effective means of providing emotional support for a toddler. The family's presence provides a sense of security that increases the child's ability to cope in an unfamiliar environment.
A nurse is assessing the pain level of a 3-year-old child who is postoperative following abdominal surgery. Which of the following pain scales should the nurse use? A. Word graphic rating scale - A word graphic rating scale uses a line with words identifying a scale of no pain to worst possible pain. Children ages 4 to 17 place a line on the scale that describes their pain. Children who are 3 years old will have difficulty understanding the words. B. Color tool - The color tool uses four markers for the child to represent pain at various levels. Children ages 4 and older can use this tool. Children who are 3 years old might have difficulty remembering what each marker represents. .C. FACES pain rating scale D. Numeric scale - Using a numeric scale from 0 to 10 to rate pain requires the child to understand numbers. This tool is helpful for children ages 5 and older.
C. FACES pain rating scale - The FACES scale is a scale that looks at various faces, which represent various levels of pain. A 3-year-old child is able to identify faces that represent different pain levels.
A nurse is caring for an 8-year-old child who has sickle cell anemia. Which of the following actions should the nurse take? A. Apply cool compresses to the painful area. - Cool compresses cause vasoconstriction and might cause further occlusions. B. Initiate contact isolation precautions. - A child who has an infection that she transmits by direct contact, such as Clostridium difficile, requires contact precautions. C. Give the child flavored popsicles. D. Administer phytonadione. - A client who has a warfarin overdose should receive phytonadione. A child who has sickle cell anemia should not receive a warfarin antidote.
C. Give the child flavored popsicles. - Maintaining hydration with a child who has sickle cell anemia is important to prevent sickling. Children accept flavored popsicles as a source of fluid.
A nurse is caring for a 6-month-old infant who has intussusception. Which of the following actions should the nurse take? A. Prepare to administer high-dose steroids.- Intussusception is not an inflammatory process, but a mechanical obstruction. B. Give the child magnesium hydroxide PO. - Abdominal pain observed with intussusception is a contraindication for receiving magnesium hydroxide, a laxative. In addition, children such as these are NPO and should not receive anything by mouth. C. Prepare the child for a barium enema. D. Educate the parents that the child will need a colostomy.- In the event of surgical intervention, the provider will remove the nonviable portion of the bowel so the bowel is anastomosed, with no need for a colostomy.
C. Prepare the child for a barium enema.- The pressure created by a barium enema might force the bowel to resume a normal configuration. Some children are treated with the barium enema and do not require surgical intervention.
A nurse is teaching a school-age child who is to undergo a bone marrow aspiration. Which of the following statements should the nurse make? A. "I will give you an antibiotic before your procedure." - The child should not receive an antibiotic prior to a bone marrow biopsy, because the use of an antibiotic might skew the test results. B. "I will place you on your side during the procedure." - The child should be in the prone position because the provider will obtain the specimen from the iliac crest. C. "You might have a headache following the procedure." - Bone marrow aspiration will not affect the brain or its fluids. Lumbar punctures are likely to cause headaches. D. "I will place a pressure dressing over the area following the procedure."
D. "I will place a pressure dressing over the area following the procedure." - Applying a pressure dressing over the area following the procedure helps to prevent bleeding from the site.
A nurse is teaching to a group of parents of adolescents about developmental needs. Which of the following statements by a parent should the nurse investigate further? A. "My child has frequent mood swings." - Adolescents strive for independence and commonly have frequent mood changes. B. "My child has a very messy bedroom." - Many adolescents assert their independence by controlling what they can. Their environment, in this case the bedroom, is one area where they feel they can assert control. C. "My child takes 1 to 2 showers per day." - Adolescents are very preoccupied with their body image and how they appear to others. Therefore, they might shower more than once daily to maintain their self-appearance. D. "My child spends 4 hours per day in Internet chat rooms."
D. "My child spends 4 hours per day in Internet chat rooms." - Adolescents might spend time using a computer, but parents should know what they are doing, who they are communicating with, and limit the time. The American Academy of Pediatrics guidelines recommend 2 hr of screen time daily.
A nurse is teaching a group of parents of toddlers about growth and development. A parent asks, "why does my child's abdomen stick out?" Which of the following statements should the nurse make? A. "You should give your child a stool softener daily." - Constipation is not the cause of the toddler's protruding abdomen. B. "Toddlers gain weight at a rapid pace." - Toddlers are not growing as rapidly as they did in infancy, and weight gain does not cause a protruding abdomen. C. "You should have your child assessed for a spinal deformity." - A spinal deformity is not the cause of the toddler's protruding abdomen. D. "Toddlers do not have well-developed abdominal muscles."
D. "Toddlers do not have well-developed abdominal muscles." - The abdominal muscles are immature and not well developed at this stage. Therefore, it is common for a toddler to have a "potbellied" appearance.
A nurse is teaching the parents of an infant who has congenital hypothyroidism. Which of the following statements should the nurse make? A. "Your child will need to take estrogen daily when she reaches puberty." - The child who has congenital hypothyroidism does not require estrogen replacement. B. "Your child will need monthly blood coagulation studies." - The child who has congenital hypothyroidism does not have a blood coagulation disorder. C. "Your child will need surgery to remove the diseased thyroid." - The child who has congenital hypothyroidism has a thyroid gland that is absent, small, or malfunctioning; however, the child does not require surgical removal of the gland. D. "Your child will need to take thyroid hormone replacement for her entire life."
D. "Your child will need to take thyroid hormone replacement for her entire life." - In congenital hypothyroidism, the child does not manufacture an adequate amount of thyroid hormone to maintain the appropriate metabolic rate. The child will require life-long thyroid hormonal replacement for normal growth and development.
A nurse is planning care for a 6-year-old child who is receiving chemotherapy. The child has a highlight platelet count of 20,000/mm3. Based on this laboratory value, which of the following interventions should the nurse include in the plan of care? A. Provide foods high in iron. - Iron is given to a child who has anemia. A platelet count of 20,000/mm3 is not an indication of an anemic condition. B. Avoid people who have infections. - Platelets are the blood component associated with clotting. C. Administer PRN oxygen. - RBCs are the blood component responsible for carrying oxygen to body tissues. The issue in this question is platelet count, which is associated with the blood's ability to clot. D. Encourage quiet play.
D. Encourage quiet play. - A platelet count of 20,000/mm3 will predispose the client to excessive bleeding. Quiet play will lessen the client's risk for injury, thereby reducing the chance of hemorrhage.
A nurse is caring for a child who has tetralogy of Fallot. Which of the following laboratory values should the nurse expect to find? A. Platelet count of 20,000/mm3 - A platelet count of 20,000/mm3 is below the expected range. A child who has Tetralogy of Fallot will not have a decreased platelet count. B. WBC 4,000/mm3 - A WBC count of 4,000/mm3 is below the expected reference range. A child who has Tetralogy of Fallot will not have neutropenia. C. Thyroid stimulating hormone 7.0 microunits/mL - This TSH level is above the expected reference range. A child who has Tetralogy of Fallot will not have changes in the thyroid function levels. D. RBC 6.8 million/uL
D. RBC 6.8 million/uL - A child who has Tetralogy of Fallot causes cyanosis; therefore, the body responds by increasing RBC production (polycythemia) in an attempt to supply oxygen to all body parts.
A nurse is caring for a child who has cystic fibrosis and a pulmonary infection, Which of the following findings is the nurse's priority? A. Blood streaking of the sputum - Blood streaking of the sputum is a common finding with children who have cystic fibrosis and a pulmonary infection; therefore, this is not the nurse's priority. B. Dry mucous membranes - Children who have cystic fibrosis might have dry mucous membranes due to malabsorption of sodium and chloride which results in dehydration; this is not the nurse's priority. C. Constipation - Constipation is common in children who have cystic fibrosis because of malabsorption of sodium and chloride resulting in dehydration; this is not the nurse's priority. D. Inability to clear secretions The nurse should apply the ABC priority
D. Inability to clear secretions - The nurse should apply the ABC priority-setting framework. This framework emphasizes the basic core of human functioning - having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life, and is therefore the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second-highest priority in the ABC priority-setting framework because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority in the ABC priority setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Therefore, the inability to clear secretions is the priority-finding because the child has a compromised airway and the nurse must act in a manner that ensures transportation of oxygen to the body's cells.
A nurse is caring for a child who has been in Buck's traction for 2 days. Which of the following actions should the nurse take to prevent complications? A. Manually move the weights to the floor when the child is experiencing pain. - The nurse should not move or adjust the weight to ensure proper alignment and correct healing. B. Check for pulses in the affected leg every 4 hr. C. Cleanse the pins every 12 hr. - Buck's traction is skin traction, which works without the use of pins. D. Inform parents to discourage visitors for the child. - The child who is in Buck's traction is not ill and should be encouraged to continue socialization through various means.
B. Check for pulses in the affected leg every 4 hr. - Traction might lead to neurovascular compromise. The nurse should assess for edema, pulses, pain, color, and temperature of the extremity every 4 hr.
A nurse is teaching the parents of a child who has rheumatic fever. Which of the following statements by a parent indicates an understanding of the teaching? A. "My child may take aspirin for his joint pain." B. "My child will need a blood transfusion prior to discharge." - A child who has rheumatic fever does not require blood transfusions, because the child does not have blood loss from this disorder. C. "I will need to wear a gown when in my child's room." - A child who has rheumatic fever only needs standard isolation precautions because rheumatic fever is an immune response that occurs after an infection with group A β-hemolytic streptococci. D. "I will apply lotion to my child's peeling hands." - Kawasaki disease causes peeling hands and rheumatic fever does not.
A. "My child may take aspirin for his joint pain." - Children who have rheumatic fever might take salicylates (aspirin) to control the inflammatory process that occurs in the joints.
A nurse is reviewing the medical record of a 2-month-old infant who has rotavirus. The nurse notes a hemoglobin level of 12g/dL and a hematocrit of 51%. Which of the following statements by the nurse indicates an understanding of the laboratory values? A. "The infant might be dehydrated." B. "The infant might be anemic." - The hemoglobin value is within the expected reference range. Clients who have anemia have a decreased hemoglobin level. C. "The infant might have received too much fluid." - Overhydration would result in a decreased hematocrit level. A hematocrit level of 51% is an increased value. D. "The infant might have leukemia." -Leukemia has a high WBC and a low RBC. These hemoglobin and hematocrit levels do not indicate impaired bone marrow production seen in leukemia.
A. "The infant might be dehydrated."- An increased hematocrit level indicates dehydration. Hematocrit levels rise when blood volume is decreased during dehydration.
A nurse is caring for a child who is receiving treatment for diabetic ketoacidosis and has a current blood glucose level of 250mg/dL. Which of the following actions should the nurse take? A. Administer 5% dextrose in 0.9% sodium chloride by continuous IV infusion. B. Give potassium as a rapid IV bolus. - Giving potassium as a rapid IV bolus is contraindicated because it can result in cardiac arrest. C. Administer 3 units of ultralente insulin subcutaneously. - Ultralente is long-acting insulin that takes 6 to 14 hr to begin working. Regular insulin will be given via IV infusion until the blood sugar reaches 250 to 300 mg/dL. If the regular insulin infusion continues, hypoglycemia can occur. D. Obtain an HbA1c level stat. - An HbA1c level measures the blood glucose level over the last 2 to 3 months and will not give useful information for the client's current status.
A. Administer 5% dextrose in 0.9% sodium chloride by continuous IV infusion. - When the child's blood glucose level falls between 250 and 300 mg/dL, the nurse should begin IV infusion of 5% or 10% dextrose in 0.9% sodium chloride. The goal is to maintain blood glucose levels between 120 and 240 mg/dL. If dextrose is not added, hypoglycemia might occur.
A school nurse is assessing an adolescent child who returned to school following a case of mononucleosis. The child has a note from his provider excusing him from gym class. Which of the following findings should the nurse identify as the reason for this excusal? A. Potential for sustaining abdominal trauma B.Deficient dietary intake - Deficient dietary intake Although an adolescent who has mononucleosis might have difficulty swallowing in the early phases of the illness, upon his return to school, he should not have deficient dietary intake. C. Exposing peers to the illness - Epstein-Barr virus causes mononucleosis and is spread primarily through direct contact with the saliva of an infected individual. Casual contact during gym and recess would be no more hazardous than having the child in a classroom. D. Straining sore joints - An adolescent who has mononucleosis will not have joint inflammation.
A. Potential for sustaining abdominal trauma An adolescent who has mononucleosis will have lymphadenopathy and often splenomegaly, which can persist for many months. For this reason, even after the adolescent is able to maintain his usual energy level and return to school, it is important for him to avoid activities that might result in trauma to the enlarged spleen.
A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions should the nurse take? A. Maintain the child on strict bed rest. - Glomerulonephritis does not require strict bed rest, because ambulation does not have an effect on the disease. However, a child might experience fatigue with glomerulonephritis and can voluntarily restrict activities when the disease is most active. B. Check the child's blood pressure every 4 hr. C. Administer albumin to the child every 8 hr. - A child who has nephrotic syndrome might require albumin to correct hypoalbuminemia and extreme edema. Administering albumin causes serum albumin levels to rise and fluid shifts from the subcutaneous spaces into the bloodstream, which decreases edema. A child who has glomerulonephritis has mild edema, so albumin is not needed. D. Provide the child with a low-carbohydrate diet. - A child who has glomerulonephritis should have limited sodium intake, but there is no restriction on carbohydrate consumption.
B. Check the child's blood pressure every 4 hr. - The nurse should check the child's blood pressure every 4 to 6 hr to monitor for hypertension.
A nurse is caring for a child who has an exacerbation of cystic fibrosis. Which of the following laboratory findings should the nurse report to the provider immediately? A. Blood glucose 140 mg/dL - A blood glucose level of 140 mg/dL is above the expected reference range and might require intervention; however, this is not the finding the nurse should report to the provider immediately. B. Oxygen saturation 85% C. RBC 3.2 million/uL - An RBC of 3.2 million/uL is below the expected reference range and might require intervention; however, this is not the finding the nurse should report to the provider immediately. D. Serum sodium 156 mEq/L - A serum sodium level of 156 mEq/L is above the expected reference range and might require intervention; however, this is not the finding the nurse should report to the provider immediately.
B. Oxygen saturation 85% - The nurse should apply the ABC priority-setting framework. This framework emphasizes the basic core of human functioning - having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life, and is therefore the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second-highest priority in the ABC priority setting framework because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority in the ABC priority setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Therefore, the nurse should report this finding to the provider immediately.
A nurse is admitting a child who has acute lymphocytic leukemia. Which of the following laboratory values should the nurse expect? A. Platelet count 500,000 mm3 - RBC 2.5 million/uL An RBC of 2.5 million/uL is below the expected reference range. A child who has acute lymphocytic leukemia has a low RBC. B. RBC 2.5 million/uL C. WBC 4,000/mm3 - A WBC of 4,000/mm3 is below the expected reference range. A child who has acute lymphocytic leukemia has a very high WBC. D. Hct 60% - An Hct of 60% is above the expected reference range. A child who has acute lymphocytic leukemia has a low Hct level.
B. RBC 2.5 million/uL - An RBC of 2.5 million/uL is below the expected reference range. A child who has acute lymphocytic leukemia has a low RBC.
A nurse is caring for a 4-year-old child who has superficial partial-thickness burns over 50% of his body. When planning for the nutritional needs of the child, which of the following actions should the nurse plan to take? A. Administer pancrelipase to the child prior to each meal. - Children who have cystic fibrosis require pancrelipase, a pancreatic enzyme to aid in digestion. Children who have cystic fibrosis are unable to have proper digestion without this medication. B. Supplement the child's feedings with enteral feedings. C. Provide the child with a low-protein meal. - Superficial partial-thickness burns affect both the outer and underlying layer of the skin, causing pain, redness, swelling, and blistering. The child who has a burn needs a high-carbohydrate and protein diet with adequate fat for healing. D. Perform dressing changes 10 min prior to the child's meals. - Dressing changes are painful, so they should not be done close to the time of feeding, since appetite and digestion might be negatively affected.
B. Supplement the child's feedings with enteral feedings. - A child who has burns in excess of 25% of total body surface area requires enteral supplementation to consume enough calories to heal.
A nurse is teaching a parent of an infant who has a colostomy. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will not dress my child in one-piece outfits." - The parent should dress the infant in one-piece outfits to restrict the infant's hands from reaching the pouch. B. "I need to buy diapers that are tighter than my infant usually wears." - The parent should use diapers that are larger than the ones the child usually wears to go over the stoma and help with drainage. C. "I need to apply paste to the back of the wafer on my child's appliance." D. "I will not need to toilet train my child." - A child who has a colostomy will need bladder training when she is developmentally ready because the urinary system is still intact.
C. "I need to apply paste to the back of the wafer on my child's appliance." - The parent should apply stoma paste to the back of the wafer on the appliance, as well as around the stoma, to act as a sealant to prevent skin breakdown.
A nurse is teaching about poisoning prevention to a group of parents who have toddlers. Which of the following statements should the nurse make? A. "Keep medications on a counter that is out of reach of the toddler." - A toddler is able to climb and can obtain many things that are out of reach. Placing medications on a high counter does not ensure the safety of the toddler. B. "Do not allow live plants in the house." - Not all plants are poisonous. Parents should remove any plants that are poisonous. C. "Put all cleaning supplies in a locked cabinet." D. "Allow your child to eat from his favorite ceramic bowls." - A toddler should not eat out of ceramic ware due to its high source of lead content.
C. "Put all cleaning supplies in a locked cabinet." - Parents should lock up cleaning supplies to provide for the safety of toddlers. Toddlers are very inquisitive and are able to open most cabinet doors without difficulty. The toddler cannot open the door of a locked cabinet.
A nurse is caring fora school-age child who has glomerulonephritis. The child has decreased urinary output, a blood pressure of 160/78 mm Hg, and is receiving hydralazine. Which of the following lunch choices should the nurse recommend? A. 1 hot dog, 22 potato chips, and 120 mL (4 oz) of orange juice - The child who has glomerulonephritis has moderate restriction of sodium and further restriction is given to foods high in potassium with children who have decreased urinary output. These restrictions are because the kidneys of these children are not functioning appropriately. This diet consists of 921 g of potassium and 734 g of sodium. B. 1 sandwich with lettuce, tomato, and 4 slices bacon, a small apple, and 240 mL (8 oz) of milk - The child who has glomerulonephritis has moderate restriction of sodium and further restriction is given to foods high in potassium with children who have decreased urinary output. These restrictions are because the kidneys of these children are not functioning appropriately. This diet is the highest option and consists of 1,119 g of potassium and 1,132 g of sodium. C. 3 oz grilled chicken, 1 cup of pear slices, and 120 mL (4 oz) of apple juice D. 1 cup of cottage cheese, a small banana, and 240 mL (8 oz) of soda - The child who has glomerulonephritis has moderate restriction of sodium and further restriction is given to foods high in potassium with children who have decreased urinary output. These restrictions are because the kidneys of these children are not functioning appropriately. This diet consists of 655 g of potassium and 712 g of sodium.
C. 3 oz grilled chicken, 1 cup of pear slices, and 120 mL (4 oz) of apple juice - The child who has glomerulonephritis has moderate restriction of sodium and further restriction is given to foods high in potassium with children who have decreased urinary output. These restrictions are because the kidneys of these children are not functioning appropriately. This diet is the lowest option and consists of 571 g of potassium and 268 g of sodium.
A nurse is caring for a child who adheres to a vegetarian diet and has sustained superficial partial-thickness burns. The nurse should recommend which of the following food choices as having the highest protein content? A. Medium baked potato - A medium baked potato has 4.32 g of protein. B. Wheat bagel with 1 tbsp of apricot jam - A wheat bagel with 1 tbsp of apricot jam has 10.14 g of protein. C. Large orange - One large orange has 1.06 g of protein. D. 1/2 cup of peanut butter with apple slices
D. 1/2 cup of peanut butter with apple slices - Peanut butter and apple slices have a total of 28.91 g of protein. This is a good choice for this client because peanut butter is high in protein, which helps with the healing process.
A nurse is assessing an adolescent who has sustained a broken tibia. Following the application of a fiberglass cast, the adolescent reports pain and a tingling feeling in the limb. Which of the following actions should the nurse take first? A. Give the adolescent ibuprofen. - The nurse should give the adolescent ibuprofen to manage the client's pain; however, there is another action the nurse should take first. B. Elevate the adolescent's leg on pillows. - The nurse should elevate the adolescent's leg on pillows to prevent edema; however, there is another action the nurse should take first. C. Place an ice pack on the cast. - The nurse might give the adolescent the ice pack to help with pain; however, there is another action the nurse should take first. D. Assess for manifestations of circulatory impairment.
D. Assess for manifestations of circulatory impairment. - The nurse should apply the ABC priority setting framework. This framework emphasizes the basic core of human functioning - having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life, and is therefore the nurse's priority concern. When applying the ABC priority setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second-highest priority in the ABC priority setting framework because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority in the ABC priority setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Therefore, the nurse should first assess for circulatory impairment to ensure there is no vascular compromise.
A nurse is caring for a child who has suspected nephrotic syndrome. Which of the following laboratory values should the nurse expect? A. Platelet count 120,000/mm3 - A platelet count of 120,000/mm3 is below the expected reference range. Children who have nephrotic syndrome have an increased platelet count because of hemoconcentration. B. Serum sodium 160 mEq/L - A serum sodium level of 160 mEq/L is above the expected reference range. Children who have nephrotic syndrome have lower than the expected serum sodium level because of hemoconcentration. C. Hgb 9 g/dL - A hemoglobin level of 9 g/dL is below the expected reference range. Children who have nephrotic syndrome will have hemoglobin levels within the expected reference range or elevated. D. Serum cholesterol 700 mg/dL
D. Serum cholesterol 700 mg/dL - A serum cholesterol level of 700 mg/dL is above the expected reference range. A child who has nephrotic syndrome will have high serum cholesterol findings because of the increase in plasma lipids.
A nurse is caring who has a vesicular rash. The parents of the child asks the nurse what illness can cause this rash for 6 days. The nurse should expert that the child has which of the following conditions? A. Measles- A child who has measles might develop Koplik spots, a transient cephalocaudal rash of maculopapular eruptions of the upper trunk and face, becoming more confluent as it spreads to the lower areas of the body. B. Fifth disease - A child who has fifth disease usually begins with bright red cheeks producing a "slapped-cheek" appearance. Following this, a rash appears on the extremities and trunk. The rash fades centrally, giving a lacy (reticulated) appearance to the rash. C. Tetanus - A child who has tetanus will develop lockjaw and muscle rigidity; however, there is no rash associated with tetanus. Nurses recommend the DTaP immunization to aid in prevention of this disease. D. Varicella
D. Varicella - Children who have varicella might commence with a maculopapular rash that progresses to vesicles on erythematous bases that eventually rupture and crust over.
