PN108 PrepU Chapter 30
You obtain a stool specimen for ova and parasites. It would be important for you to
see that it arrives at the laboratory promptly.
A pediatric nurse is instructing a new mother on the best position to burp her infant after feeding. Which of the following positions does the nurse recommend?
sitting position
Which of the following are situations that might warrant a restraint of a pediatric patient? (Select all that apply.)
to protect the child from injury during a procedure or examination to ensure the child's safety
An adolescent is scheduled to have the present gastrostomy tube replaced with a gastrostomy button. What advantage of the button over the tube will the nurse emphasize?
The button will be smaller and less visible when not in use.
The nurse is preparing a 7-year-old child for surgery. Which of the following nursing interventions is the highest priority?
The nurse should follow the facility's policies.
The nurse is administering a tube feeding to a child. The nurse aspirates the stomach contents as part of the process for checking placement of the tube. Which action is correct for the nurse to do with the aspirated stomach contents?
The nurse should measure and replace the residual stomach contents.
A nurse is preparing to insert a feeding tube into a child and lubricates the tube with water or a water-soluble jelly first. Why does the nurse avoid the use of an oil-based lubricant?
There is a danger of oil aspiration into the lungs.
A young preschooler who has been playing in the hospital playroom needs transportation to the imaging department. What conveyance will the nurse choose?
Wagon
A nurse is caring for a hospitalized infant being treated for dehydration. What does the nurse need to do to measure the output when the child is wearing a diaper?
Weigh the wet diaper and subtract the weight of a dry diaper; the difference is the amount to record
The nurse will apply which type of restraint for the infant recovering from cleft lip repair?
Elbow
A 7-year-old boy has been admitted to the hospital with a diagnosis of fever of unknown origin. He has numerous tests ordered for diagnosis. When preparing him for the blood tests ordered, the best explanation would be,
"The doctor needs to look at your blood to see why you are sick; it will hurt for a second."
A nurse has just received an order to apply an ice bag to a patient's groin. Which of the following intervals for placement of the ice bag does the nurse plan to use?
20 minutes
A nursing student is learning how to insert and administer enteral feedings through a nasogastric (NG) tube. The student identifies the best way to check placement before each feeding as which of the following?
Aspirating stomach contents and checking pH
After inserting a nasogastric tube (NG) into a young child, how will the nurse tape the tube in place?
Below nose and to cheek
After a gavage feeding has been completed for a young infant, the nurse will encourage the parent to take what action?
Burp the infant
A child has been admitted to the pediatric unit with an oral temperature of 102° F (38.9° C). acetaminophen (Tylenol) has failed to control the fever. The nurse knows that she may utilize which of the following therapeutic modalities? (Select all that apply.)
Cooling blanket Hydration Lightweight clothes Cool room
Following the repair of a cleft palate, the nurse places an 18-month-old child in restraints. The caregivers are with the child and will stay in the room at all times. Which of the following types of restraints would the nurse most likely use for this child?
Elbow restraints
When performing a procedure on a child in the health care setting, what should the priority intervention by the nurse be?
Ensuring the child's safety
The nurse is about to place a gastostomy tube in an infant. After gathering supplies, what is the first step in the procedure?
Explain the procedure to the parents.
When the nurse is holding an infant, what positions are the most common methods are used? (Select all that apply.)
Football hold Horizontal position Upright position
A nurse is caring for a 14-year-old with a gastrostomy tube. The girl has skin breakdown and irritation at the insertion site. Which would be the most appropriate method to clean and secure the gastrostomy tube?
If any drainage is present, use a presplit 2 × 2 and place it loosely around the site.
A nursing instructor is discussing oxygen therapy with a group of pediatric nursing students. Which of the following statements made by one of the students indicates a need for further teaching?
Oxygen should be removed immediately upon receiving the physician's order to stop therapy.
The nurse is caring for a client needing oxygen. Many forms of oxygen delivery can be used. Which of the following is the most difficult to manage the oxygen concentration?
Oxygen tent
A child has been admitted to the pediatric unit with diarrhea. The nurse must collect a stool specimen for ova and parasites. The nurse knows that the proper procedure must be followed for detection of the ova and parasites. The proper procedure includes:
Transport the stool specimen to the laboratory promptly.
The nurse finds an elevated temperature in a blanket-wrapped infant a mother is holding and rocking. What first temperature reduction measure will the nurse take?
Unwrap the infant and place the child in the crib
You are caring for a four month old infant who is running fever. The mother questions what can be done to get the child's temperature down. Which of the following are acceptable methods to manage fever in an infant. Select all that apply.
Use a hypothermic blanket Encourage the infant to drink fluids Use acetaminophen or other antipyretics Prevent overdressing the infant
You are caring for a 4-month-old infant who is running fever. The mother questions what can be done to get the child's temperature down. Which of the following are acceptable methods to manage fever in an infant? (Select all that apply.)
Use a hypothermic blanket. Encourage the infant to drink fluids. Use acetaminophen or other antipyretics. Prevent overdressing the infant.
The nurse notes that parents accompanying their child for a procedure appear tense and nervous. What intervention by the nurse will best assist the young child to relax?
Use measures to reduce the parents' anxiety
A 6 year old has just returned to his room after a spinal tap. What could the nurse do to make this unpleasant procedure less memorable for the child?
Give him a little toy that he has been wanting.
How will the nurse determine the length of orogastric tubing needed to gavage the 14-month-old infant?
Measure from nose tip to earlobe to end of sternum
The nurse is caring for an 11-year-old admitted with a respiratory condition. Which of the following methods of oxygen administration would likely be used for this child?
Nasal prongs
A nurse receives a physician's order to collect a specimen for the diagnosis of respiratory syncytial virus. How should the nurse collect this specimen?
Obtain a nasal washing.
A nurse is preparing to assist a physician to suture a scalp laceration for a toddler. Which restraint would be most appropriate to use for this procedure?
Papoose board
A child has been admitted to the pediatric unit with vomiting and diarrhea. The physician orders strict monitoring of intake and output. The mother asks the nurse what fluids she will need to measure. The nurse responds that fluid intake can include which of the following? (Select all that apply.)
Popsicles Gatorade Jello IV fluids
One-year-old Colin has been admitted for an injury on his head that requires sutures to be placed. He is crying and trying to sit up when he is placed on the examining table. To keep him safe during the procedure, the nurse would choose which of the following methods to restrain him?
Restrain him with a mummy restraint and release it as soon as the procedure is completed.
The nurse aspirates stomach contents before administering a nasogastric (NG) tube feeding. How will the nurse manage the aspirate? Select all that apply.
Return the aspirate to the stomach Determine the pH of the aspirate Record the amount of the aspirate
The nurse wishes to promote gastric emptying after administering the preschooler's gastrostomy feeding. Which position will facilitate this?
Right side-lying
A nurse is unsure whether the nasogastric (NG) tube just placed is properly positioned in the child's stomach. How can the nurse most accurately verify the location of the tube?
Seek radiologic confirmation
An older school-age child is taught to apply warm nonsterile compresses to an inflamed area on one leg. Which suggestion by the nurse will increase the effectiveness and safety of the child's self-care?
Set a timer for not longer than 20 minutes as a removal reminder.
The nurse should consider which stool sample collected from a child as contaminated and not acceptable for analysis?
Stool removed from surrounding urine
A nurse is administering a bolus nasogastric (NG) feeding to a child who begins gasping, coughing, and developing cyanosis. What is the first action that the nurse should take after this observation?
Stop the feeding and withdraw the tube.
You have just inserted a nasogastric tube for an enteral feeding in a 6-month-old infant. The best way to assess whether the tube has reached her stomach is to:
aspirate the tube for stomach contents.
A pediatric nurse is teaching a class about SIDS to new mothers. Which of the following positions for sleep would the nurse emphasize for parents to use?
back or side
An infant is admitted to the hospital for cleft palate surgery. The type of restraint you would use with the infant postoperatively would be
elbow restraints
A nurse is preparing to apply heat therapy to a patient who has a back abscess. Heat has which of the following benefits? (Select all that apply.)
increases circulation causes vasodilation promotes muscle relaxation
A nursing student is instructed to collect a urine specimen from a 3 week old. Which of the following would be the nurse's best option?
placing cotton balls in the diaper and squeezing out urine
