RN Nursing Care of Children Online Practice 2019 A with NGN
A nurse is reviewing the laboratory report of a 7-year-old child who is receiving chemotherapy. Which of the following laboratory values should the nurse report to the provider? Hgb 8.5 g/dL WBC count 9,500/mm3 Prealbumin 18 mg/dL Platelets 300,000/mm3
Hgb 8.5 g/dL A child receiving chemotherapy is at risk for anemia due to the chemotherapy effects on the blood-forming cells of the bone marrow. The development of anemia is diagnosed through laboratory testing of hemoglobin and hematocrit levels. The nurse should recognize that a hemoglobin level of 8.5 g/dL is below the expected reference range of 10 to 15.5 g/dL for a 7-year-old child and should be reported to the provider.
A nurse is caring for a toddler who has spastic (pyramidal) cerebral palsy. Which of the following findings should the nurse expect? (Select all that apply.) Negative Babinski reflex Ankle clonus Exaggerated stretch reflexes Uncontrollable movements of the face Contractures
Ankle clonus is correct. The nurse should expect a child who has spastic cerebral palsy to exhibit ankle clonus, which is a rhythmic reflex tremor when the foot is dorsiflexed Exaggerated stretch reflexes is correct. The nurse should expect a child who has spastic cerebral palsy to exhibit spasticity or exaggerated stretch reflexes. . Contractures is correct. The nurse should expect a child who has spastic cerebral palsy to exhibit contractures due to the tightening of the muscles.
A nurse is reviewing the lumbar puncture results of a school-age child who is suspected of having bacterial meningitis. Which of the following findings should the nurse identify as an indication of bacterial meningitis? Decreased cerebrospinal fluid pressure Decreased WBC count Increased protein concentration Increased glucose level
Increased protein concentration The nurse should identify that an increased protein concentration in the spinal fluid is a finding that can indicate bacterial meningitis.
A nurse is caring for a toddler who is experiencing acute diarrhea and has moderate dehydration. Which of the following nutritional items should the nurse offer to the toddler? Apple juice Peanut butter Chicken broth Oral rehydration solution
Oral rehydration solution A toddler who has acute diarrhea should consume an oral rehydration solution to replace electrolytes and water by promoting the reabsorption of water and sodium. This promotes recovery from dehydration.
A nurse is creating a plan of care for a school-age child who has heart disease and has developed heart failure. Which of the following interventions should the nurse include in the plan? Provide small, frequent meals for the child. Schedule time in the play room for the child. Weigh the child weekly. Maintain the child in a supine position.
Provide small, frequent meals for the child. The metabolic rate of a child who has heart failure is high because of poor cardiac function. Therefore, the nurse should provide small, frequent meals for the child because it helps to conserve energy.
A nurse is auscultating the lungs of an adolescent who has asthma. The nurse should identify the sound as which of the following? (Click on the audio button to listen to the clip.) Biot respiration Cheyne-Stokes respiration Tachypnea Bradypnea
Tachypnea The nurse should identify the sound heard during auscultation as tachypnea, which is a rapid, regular breathing pattern. This breathing pattern often occurs with anxiety, fever, metabolic acidosis, or severe anemia.
A nurse is assessing a toddler who has gastroenteritis and is exhibiting manifestations of dehydration. Which of the following findings is the nurse's priority? Skin breakdown Hypotension Hyperpyrexia Tachypnea
Tachypnea When using the airway, breathing, and circulation approach to client care, the nurse's priority finding is the toddler's tachypnea. Tachypnea is a result of the kidneys being unable to excrete hydrogen ions and produce bicarbonate, which leads to metabolic acidosis.
A nurse is caring for a school-age child who is receiving chemotherapy and is severely immunocompromised. Which of the following actions should the nurse take? Use surgical asepsis when providing routine care for the child. Administer the measles, mumps, and rubella (MMR) vaccine to the child. Screen the child's visitors for indications of infection. Infuse packed RBCs.
Screen the child's visitors for indications of infection. A child who is severely immunocompromised is unable to adequately respond to infectious organisms, resulting in the potential for overwhelming infection. Therefore, the nurse should screen the child's visitors for indications of infection.
A nurse is creating a plan of care for an infant who has an epidural hematoma from a head injury. Which of the following interventions should the nurse include in the plan? Position the infant side-lying with their head at a 0° to 5° angle. Perform a neurological assessment every 4 hr. Suction the infant's nares to remove secretions. Implement seizure precautions for the infant.
Implement seizure precautions for the infant. An infant who has an epidural hematoma is at great risk for seizure activity. Therefore, the nurse should implement seizure precautions for the child.
A nurse is planning care for a toddler who has a serum lead level of 4 mcg/dL. Which of the following actions should the nurse plan to take? Instruct the parents to decrease the calcium in their toddler's diet. Prepare the toddler for chelation therapy. Refer the family to Child Protective Services. Schedule the toddler for a yearly rescreening.
Schedule the toddler for a yearly rescreening. The nurse should schedule the toddler for a lead level rescreening in 1 year and educate the family on ways to prevent exposure.
A nurse in an emergency department is caring for a toddler who has partial-thickness burns on their right arm. Which of the following actions should the nurse take? Insert a nasogastric tube. Initiate prophylactic antibiotic therapy. Cleanse the affected area with mild soap and water. Apply a topical corticosteroid to the affected area.
Cleanse the affected area with mild soap and water. The nurse should wash the affected area with mild soap and water to remove any loose tissue that could cause infection.
A nurse is caring for an infant who has RSV Messed up Question Sorry !!!!! Have a designated stethoscope in the infant's room. Place the infant in a room equipped with negative airflow. Administer palivizumab as prescribed for the infant. Remove gloves after leaving the infant's room.
Have a designated stethoscope in the infant's room. The nurse should initiate droplet precautions for an infant who has RSV because the virus is spread by direct contact with respiratory secretions. Therefore, designated equipment, such as a blood pressure cuff and a stethoscope, should be placed in the infant's room.
A school nurse is assessing an adolescent who has scoliosis. Which of the following findings should the nurse expect? Increase in anterior convexity of the lumbar spine Increased curvature of the thoracic spine Lateral flexion of the neck A unilateral rib hump
A unilateral rib hump When assessing an adolescent for scoliosis, the school nurse should expect to see a unilateral rib hump with hip flexion. This results from a lateral S- or C-shaped curvature to the thoracic spine resulting in asymmetry of the ribs, shoulders, hips, or pelvis. Scoliosis can be the result of a neuromuscular or connective tissue disorder, or it can be congenital in nature.
A nurse is planning care for a school-age child who is in the oliguric phase of acute kidney injury (AKI) and has a sodium level of 129 mEq/L. Which of the following interventions should the nurse include in the plan? Administer ibuprofen to the child for a temperature greater than 38º C (100.4º F). Assess the child's blood pressure every 8 hr. Weigh the child weekly at various times of the day. Initiate seizure precautions for the child.
Initiate seizure precautions for the child. A sodium level of 129 mEq/L indicates hyponatremia and places the child at increased risk for neurological deficits and seizure activity. The nurse should complete a neurologic assessment and implement seizure precautions to maintain the child's safety.
A nurse is caring for a school-age child who has experienced a tonic-clonic seizure. Which of the following actions should the nurse take during the immediate postictal period? Place the child in a side-lying position. Delay documentation until the child is fully alert. Give the child a high-carbohydrate snack. Administer an oral sedative to the child.
Place the child in a side-lying position. The nurse should place the child in a side-lying position to prevent aspiration.
A nurse is reviewing the laboratory report of an infant who is receiving treatment for severe dehydration. The nurse should identify that which of the following laboratory values indicates effectiveness of the current treatment? Potassium 2.9 mEq/L Sodium 140 mEq/L Urine specific gravity 1.035 BUN 25 mg/dL
Sodium 140 mEq/L The nurse should identify that a sodium level of 140 mEq/L is within the expected reference range of 134 to 150 mEq/L and indicates the current treatment regimen the infant is receiving for dehydration is effective.
A nurse in an emergency department is performing a physical assessment on a 2-week-old male newborn. Which of the following findings is the priority for the nurse to report to the provider? Excoriated scrotal area Multiple capillary hemangiomas Depressed posterior fontanel Substernal retractions
Substernal retractions When using the airway, breathing, and circulation approach to client care, the nurse should determine that the priority finding to report to the provider is substernal retractions. This finding indicates the newborn is experiencing increased respiratory effort, which could quickly progress to respiratory failure.
A charge nurse in an emergency department is preparing an in-service for a group of newly licensed nurses about the manifestations of child maltreatment. Which of the following manifestations should the charge nurse include as a potential indication of physical abuse? Recurrent urinary tract infections Symmetric burns of the lower extremities Failure to thrive Lack of subcutaneous fat
Symmetric burns of the lower extremities The nurse should include that symmetric burns to the lower extremities can indicate physical abuse. The patterns are usually characteristic of the method or object used, such as cigar or cigarette burns, or burns in the shape of an iron.
Messed up Question Sorry !!!!! Blood pressure 130/90 mm Hg Heart rate 60/min Temperature 39.1° C (102.4° F) Urinary output 100 mL/hr
Temperature 39.1° C (102.4° F) The nurse should identify that a temperature of 39.1° C (102.4° F) is above the expected reference range of 37° to 37.5° C (98.6° to 99.5° F) for a 10-year-old child. The nurse should expect a child who has early septic shock to have a fever and chills.
A nurse is providing dietary teaching to the parent of a school-age child who has celiac disease. The nurse should recommend that the parent offer which of the following foods to the child? Wheat crackers Rye bread Barley soup White rice
White rice The nurse should recommend that the parent offer white rice to the child because it is a gluten-free food. The nurse should instruct the parent that the child will remain on a lifelong gluten-free diet and the child should not consume oats, rye, barley, or wheat, and sometimes lactose deficiency can be secondary to this disease.
A nurse is teaching the guardian of a 6-month-old infant about car seat use. Which of the following statements by the guardian indicates an understanding of the teaching? "I should secure the car seat using lower anchors and tethers instead of the seat belt." "I should position the car seat harness 1 inch above my baby's shoulders." "I will make sure that the car seat is placed at a 90-degree angle." "I will pad my baby's car seat with a blanket for traveling long distances."
"I should secure the car seat using lower anchors and tethers instead of the seat belt." Lower anchors and tethers, or the LATCH child safety seat system, should be used to secure an infant's car seat in the vehicle. This system provides anchors between the front cushion and the back rest for the car seat. Therefore, if this system is available, the seat belt does not have to be used
A nurse is caring for a 15-year-old client who is married and is scheduled for a surgical procedure. The client asks, "Who should sign my surgical consent?" Which of the following responses should the nurse make? "You can sign the consent form because you are married." "Your spouse should sign the consent form for you." "Your parent should sign the consent form for you." "You can appoint a legal guardian to sign the consent form."
"You can sign the consent form because you are married." The nurse should inform the adolescent that marriage gives adolescents the legal right to consent to surgical procedures and sign other legal documents that they would not otherwise be able to sign due to their age.
A nurse is caring for a preschooler whose father is going home for a few hours while another relative stays with the child. Which of the following statements should the nurse make to explain to the child when their father will return? "Your daddy will be back at 7 p.m." "Your daddy will be back after he takes care of your brother." "Your daddy will be back in the morning." "Your daddy will be back after you eat."
"Your daddy will be back after you eat." Preschoolers make sense of time best when they can associate it with an expected daily routine, such as meals and bedtime. Therefore, the child comprehends time best when it is explained to them in relation to an event they are familiar with, such as eating..
A nurse in a provider's office is caring for a preschooler. Nurses' Notes 0915:Guardians report that lately the child has had severe itching and is breaking out with sores on their eyebrows, wrists, and ankles. The "sores started to bleed." Guardians report no relief with application of the topical hydrocortisone cream.0930:Child is alert. Multiple small erythematous papules with some scaling noted on the child's eyebrows, forearms, and lower legs bilaterally.1015:Provider in to evaluate the child. Discharge to home after medication administration of new prescriptions and discharge teaching for atopic dermatitis. Medical History Family history of atopic dermatitis Medication Administration Record 1000:Loratadine (oral solution) 5 mg PO daily. Administer first dose now prior to discharge.Tacrolimus 0.03% ointment. Apply thin layer to affected areas twice daily; rub in gently and completely.Return to primary care provider in 1 to 2 weeks for evaluation. Which of the following statements by a guardian indicate that the discharge teaching was effective? Select all that apply. "We should apply a skin emollient immediately after bathing our child." "We should keep our child's fingernails tri
"We should apply a skin emollient immediately after bathing our child" is correct. An emollient is an oil that moisturizes the skin and should be applied immediately after bathing while the skin is damp to prevent drying. Therefore, this statement by the guardian indicates the teaching has been effective "We should keep our child's fingernails trimmed short" is correct. The child's fingernails and toenails should be kept short, trimmed, and filed to prevent scratching with sharp edges. Therefore, this statement by the guardian indicates the teaching has been effective. g. "We should use a mild detergent for our laundry" is correct. The use of mild detergents for laundry helps prevent allergens and itching. Therefore, this statement by the guardian indicates the teaching has been effective.
A nurse is assessing a 4-year-old child at a well-child visit. Which of the following developmental milestones should the nurse expect to observe? Identifies right from left hand Uses a utensil to spread butter Cuts an outlined shape using scissors Draws a stick figure with seven body parts
Cuts an outlined shape using scissors The nurse should recognize that an expected developmental milestone of a 4-year-old child is using scissors to cut out a shape.
A school nurse is assessing an adolescent who has multiple burns in various stages of healing. Which of the following behaviors should the nurse identify as a possible indication of physical abuse? Expresses a reluctance to leave home Provides a detailed description of how the burns occurred Denies discomfort during assessment of injuries Describes strong relationships with peers
Denies discomfort during assessment of injuries The nurse should suspect child maltreatment in the form of physical abuse if the adolescent has a blunted response to painful stimuli or injury.
The nurse is continuing to care for the child. Nurses' Notes 0800: Child is awake, watching cartoons on TV, and parent is at bedside. IV site in right antecubital is without redness or edema and dressing is dry and intact. Dressings to left arm and hand, anterior neck, and anterior chest are moderately saturated with serous drainage and several small spots of serosanguineous drainage. Dressings remain intact and smell malodorous. Breath sounds are equal and clear bilaterally. Respirations are unlabored. Abdomen is soft and nondistended. Mucous membranes are moist. Skin turgor is slightly brisk. Pupils are equal, round, and reactive to light and accommodation. Child is oriented to place, time, and name. When child attempts to move, they begin to cry. Child reports pain as 8 on the FACES scale. Noted a 1 cm x 2 cm stage 1 pressure injury on the right side of the occiput. Prepared child and parent for transport to hydrotherapy and debridement scheduled for 0830. 0815: Pediatric Burn Unit Nurses' Notes Provider notified of 0800 assessment and vital signs. Provider will examine child during hydrotherapy. Morphine given for pain rating of 8 on FACES pain rating scale. Child transported via str
Change the morphine route to family-controlled analgesia via a PCA pump is anticipated. A pain rating of 8 indicates severe pain. The use of a PCA pump should increase the effectiveness of pain management during movement and procedures. The nurse should teach the child's primary caregiver about the use of the PCA pump. Obtain a wound culture is anticipated. The child has an elevated temperature and malodorous green wound drainage. The nurse should obtain a wound culture to determine the causative organism and an antibiotic should be administered. Place the child on a pressure-reduction mattress is anticipated. The child has developed a stage 1 pressure injury on their occiput. A pressure-reduction mattress can help prevent further tissue injury. Limit daily protein intake is contraindicated. Children who have major burns require a high-protein, high-calorie diet to help with wound healing. The nurse should provide high-protein snacks to the child between meals.~
A school nurse is preparing to administer atomoxetine 1.2 mg/kg/day PO to a school-age child who weighs 75 lb. Available is atomoxetine 40 mg/capsule. How many capsules should the nurse administer per day? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)
The nurse should administer atomoxetine 1 capsule PO each day.
Provider PrescriptionsTuberculin skin test (TST)Measles, mumps, and rubella (MMR) vaccineInactivated influenza vaccineDiphtheria, tetanus, and pertussis (DTaP) vaccine Graphic RecordRespiratory rate 24/minHeart rate 115/minTemperature 36.9° C (98.4° F) History and PhysicalAge 15 monthsHeight 71.1 cm (28 in)Allergies Neomycin (anaphylactic reaction)Caregiver reports rhinitis with clear nasal drainage for 2 daysOccasional nonproductive cough for 2 daysHistory of asthma A nurse in a provider's office is preparing to administer immunizations to a toddler during a well-child visit. Which of the following actions should the nurse plan to take? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data.) Withhold the measles, mumps, and rubella (MMR) vaccine. Withhold the diphtheria, tetanus, and pertussis (DTaP) vaccine. Withhold the influenza vaccine. Withhold the tuberculin skin test (TST).
Withhold the measles, mumps, and rubella (MMR) vaccine. The nurse should recognize that an allergy to neomycin with an anaphylactic reaction is a contraindication for receiving the MMR vaccine. Clients who have a severe allergy to eggs or gelatin should not receive this vaccine.
A nurse is providing teaching to the parent of an infant who has diaper dermatitis. The nurse should instruct the parent to apply which of the following to the affected area? Zinc oxide Antibiotic ointment Talcum powder Antiseptic solution
Zinc oxide Diaper dermatitis is a common inflammatory skin disorder caused by contact with an irritant such as urine, feces, soap, or friction, and takes the form of scaling, blisters, or papules with erythema. Providing a protective barrier, such as zinc oxide, against the irritants allows the skin to heal.
A nurse is providing teaching to the parent of a school-age child who has a new prescription for oral nystatin for the treatment of oral candidiasis. Which of the following instructions should the nurse include? "Shake the medication prior to administration." "Provide the medication through a straw." "Rinse the child's mouth with water immediately after giving the medication." "Mix the medication with applesauce if the child dislikes the taste."
"Shake the medication prior to administration." The nurse should instruct the parent to shake the medication prior to administration to disperse the medication evenly within the suspension.
A nurse in an emergency department is caring for an adolescent who has severe abdominal pain due to appendicitis. Which of the following locations should the nurse identify as McBurney's point? (You will find "hot spots" to select in the artwork below. Select only the hot spot that corresponds to your answer.)
A is correct
A nurse is teaching the parent of an infant about ways to prevent sudden infant death syndrome (SIDS). Which of the following instructions should the nurse include? "Place the infant in a prone position to sleep." "Allow the infant to sleep on a large pillow." "Use a soft mattress in the infant's crib." "Give the infant a pacifier at bedtime."
"Give the infant a pacifier at bedtime." The nurse should inform the parent that protective factors against SIDS include breastfeeding and the use of a pacifier when the infant is sleeping.
A nurse is teaching a school-age child who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the child indicates an understanding of the teaching? "I will puncture the pad of my finger when I am testing my blood glucose." "I will give myself a shot of regular insulin 30 minutes before I eat breakfast." "I will eat a snack of 5 grams of carbohydrates if my blood glucose is low." "I will decrease the amount of fluids I drink when I am sick."
"I will give myself a shot of regular insulin 30 minutes before I eat breakfast." The child should administer regular insulin 30 min before meals so that the onset coincides with food intake.
A hospice nurse is caring for a preschooler who has a terminal illness. One of the preschooler's parents tells the nurse that they cannot cope anymore and are thinking about moving out of the house. Which of the following statements should the nurse make? "It is important that you provide emotional support for your family at this time." "You have to do what you feel is best. Everything will turn out fine." "I know how you feel. This is an extremely stressful time for your family." "Let's talk about some of the ways you have handled previous stressors in your life."
"Let's talk about some of the ways you have handled previous stressors in your life." This statement offers a general lead to allow the parent to express their feelings and previous actions when faced with stressful situations. It also helps the parent to focus on ways that they can cope with the current situation.
A nurse is caring for a school-age child who is in Buck's traction following a leg fracture 24 hr ago. Which of the following actions should the nurse take? Change the child's position every 2 hr. Clean the peripheral pin sites with chlorhexidine solution every 4 days. Assess peripheral pulses once every 4 hr. Ensure that the head of the bed is elevated to a 90° angle.
Assess peripheral pulses once every 4 hr. Buck's traction is a type of skin traction that can be used to immobilize extremities prior to surgery. The nurse should provide frequent neurovascular checks at least every 4 hr after the first 24 hr of placement in Buck's traction. The nurse should monitor and report signs of neurovascular impairment in the extremities such as cyanosis, edema, pain, absent pulses, and tingling.
A nurse is caring for a preschooler who has been receiving IV fluids via a peripheral IV catheter. When preparing to discontinue the IV fluids and catheter, which of the following actions should the nurse plan to take? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
First, the nurse should turn off the IV pump. Next, the nurse should occlude the IV tubing, and then remove the tape securing the catheter. Last, the nurse should apply pressure over the catheter insertion site.
A nurse is caring for a school-age child who is receiving a blood transfusion. Which of the following manifestations should alert the nurse to a possible hemolytic transfusion reaction? Laryngeal edema Flank pain Distended neck veins Muscular weakness
Flank pain The nurse should recognize that flank pain is caused by the breakdown of RBCs and is an indication of a hemolytic reaction to the blood transfusion.
A nurse is admitting a school-age child who has pertussis. Which of the following actions should the nurse take? Place the child in a room with positive-pressure airflow. Place the child in a room with negative-pressure airflow. Initiate contact precautions for the child. Initiate droplet precautions for the child.
Initiate droplet precautions for the child. The nurse should initiate droplet precautions for a child who has pertussis, also known as whooping cough. Pertussis is transmitted through contact with infected large-droplet nuclei that are suspended in the air when the child coughs, sneezes, or talks.
A nurse is caring for an adolescent who received a kidney transplant. Which of the following findings should the nurse identify as an indication the adolescent is rejecting the kidney? Negative leukocyte esterase Serum creatinine 3.0 mg/dL Negative urine protein Urine output 40 mL/hr
Serum creatinine 3.0 mg/dL Creatinine is a byproduct of protein metabolism and is excreted from the body through the kidneys. An elevated serum creatinine level, therefore, can be an indication that the kidneys are not functioning. The nurse should identify that the adolescent's serum creatinine level is higher than the expected reference range of 0.4 to 1.0 mg/dL for an adolescent and can indicate rejection of the kidney.
A nurse is preparing to collect a sample from a toddler for a sickle-turbidity test. Which of the following actions should the nurse plan to take? Obtain a sputum specimen. Perform an Allen test. Perform a finger stick. Obtain a stool specimen.
Perform a finger stick. The nurse should perform a finger stick on a toddler as a component of the sickle-turbidity test. If the test is positive, hemoglobin electrophoresis is required to distinguish between children who have the genetic trait and children who have the disease.
A nurse is providing teaching about play activities for social development to the parents of a preschooler. Which of the following play activities should the nurse recommend for the child? Playing pat-a-cake Using a push-pull toy Creating a scrapbook Playing dress-up
Playing dress-up The nurse should instruct the parents that at the preschool age, play should focus on social, mental, and physical development. Therefore, playing dress-up is a recommended play activity for this chil
A nurse is reviewing the laboratory report of a school-age child who is experiencing fatigue. Which of the following findings should the nurse recognize as an indication of anemia? Hematocrit 28% Hemoglobin 13.5 g/dL WBC count 8,000/mm3 Platelets 250,000/mm3
Hematocrit 28% The nurse should recognize that this hematocrit level is below the expected reference range of 32% to 44% for a school-age child. The child can exhibit fatigue, lightheadedness, tachycardia, dyspnea, and pallor due to the decreased oxygen-carrying capacity.
A nurse is caring for a school-age child who is receiving cefazolin via intermittent IV bolus. The child suddenly develops diffuse flushing of the skin and angioedema. After discontinuing the medication infusion, which of the following medications should the nurse administer first? Prednisone Epinephrine Diphenhydramine Albuterol
Epinephrine This child is most likely experiencing an anaphylactic reaction to the cefazolin. According to evidence-based practice, the nurse should first administer epinephrine to treat the anaphylaxis. Epinephrine is a beta adrenergic agonist that stimulates the heart, causes vasoconstriction of blood vessels in the skin and mucous membranes, and triggers bronchodilation in the lungs.
A nurse in an emergency department is caring for a school-age child who has appendicitis and rates their abdominal pain as 7 on a scale of 0 to 10. Which of the following actions should the nurse take? Instill a 500 mL tap water enema. Give morphine 0.05 mg/kg IV. Administer polyethylene glycol 1g/kg PO. Apply a heating pad to the child's abdomen.
Give morphine 0.05 mg/kg IV. A pain level of 7 on a scale of 0 to 10 is considered severe. The nurse should administer an analgesic medication for pain relief.
A nurse is assessing a school-age child who has meningitis. Which of the following findings is the priority for the nurse to report to the provider? Reports a headache as 6 on a 0 to 10 pain scale Petechiae on the lower extremities Nuchal rigidity Positive Kernig's sign
Petechiae on the lower extremities The presence of a petechial or purpuric rash on a child who is ill can indicate the presence of meningococcemia. This type of rash indicates the greatest risk of serious rapid complications from sepsis and should be reported immediately to the provider.
The nurse is caring for the child 14 days after admission. Graphic Record 0800: Temperature 37° C (98.6° F)Heart rate 100/minRespiratory rate 20/minBlood pressure 98/56 mm HgSaO2 97% on room airWeight 16.8 kg (37 lb)1300: Temperature 35.8° C (96.4° F)Heart rate 68/minRespiratory rate 14/minBlood pressure 90/50 mm HgSaO2 88% on room air Nurses' Notes Pediatric Burn Unit 0800: Reinforced preoperative teaching with the child and parent. Child is awake and alert. Moving all extremities. Child limits their range-of-motion of the left arm. Anterior neck and upper chest dressings are dry and intact. Left arm and hand dressings are intact and slightly moist with serous drainage. Breath sounds are clear and equal bilaterally. Abdomen is soft and nondistended. Bowel sounds are active in all quadrants. Child remains NPO for surgery. Right antecubital peripherally inserted central catheter (PICC) line dressing is dry and intact. Site is without redness, edema, or drainage. IV maintenance fluids and PCA morphine are infusing through PICC line. Child reports pain as 2 on the FACES pain scale.PACU Nurse 1245: Anterior neck and left chest dressings are dry and intact. Left thigh dressing has a modera
Provide 100% oxygen via face mask is correct. The nurse should provide 100% oxygen via face mask to the child because of their SaO2 and respiratory rate. The SaO2 should be maintained at 95% or higher and if the SaO2 falls below 95%, supplemental oxygen should be initiated. Check anterior neck and chest dressing for bleeding is correct. Upon return from the procedure, all surgical dressings should be assessed for drainage and to ensure the dressing is intact. Place a warm blanket on the child is correct. The child is exhibiting hypothermia. It is important for the child to have a stable body temperature because vasoconstriction can diminish blood flow to the surgical sites and impair healing. Keep the child's head in a neutral position is correct. The child's head should be kept in a neutral alignment to prevent hyperextension or hyperflexion and to prevent graft loss.
The nurse is caring for the child 4 days after admission. Graphic Record 0800: Temperature 38.8° C (101.8° F)Heart rate 124/minRespiratory rate 22/minBlood pressure 100/56 mm HgSaO2 97% on room airWeight 17.1 kg (37.7 lb)Urine output 15 mL in past hour Nurses' Notes 0800: Child is awake, watching cartoons on television, and parent is at bedside. IV site in right antecubital is without redness or edema and dressing is dry and intact. Dressings to left arm and hand, anterior neck, and anterior chest are moderately saturated with serous drainage and several small spots of serosanguineous drainage. Dressings remain intact and smell malodorous. Breath sounds are equal and clear bilaterally. Respirations are unlabored. Abdomen is soft and nondistended. Mucous membranes are moist. Skin turgor is slightly brisk. Pupils are equal, round, and reactive to light and accommodation. Child is oriented to place, time, and name. When child attempts to move, they begin to cry. Child reports pain as 8 on the FACES scale. Noted a 1 cm x 2 cm stage 1 pressure injury on the right side of the occiput. Prepared child and parent for transport to hydrotherapy and debridement scheduled for 0830. Provider Prescri
Dropdown 1: Temperature is correct. When using the urgent vs. nonurgent approach to client care, the nurse should determine that an increased temperature is a priority finding, because it can indicate an infection and sepsis. Wound sepsis is most likely to occur between the third and fifth day after a burn. Therefore, the nurse should first address the child's temperature. Dropdown 2: Pain is correct. When using the urgent vs. nonurgent approach to client care, the nurse should determine that an 8 out of 10 pain rating on the FACES scale is a priority finding and should be addressed next. Severe pain impacts the stress response, which can lead to complications and adversely affect healing.
A nurse is receiving change-of-shift report for four children. Which of the following children should the nurse see first? A school-age child who has sickle cell anemia and reports decreased vision in the left eye A school-age child who has cystic fibrosis and a frequent nonproductive cough A preschooler who has asthma and a peak flow meter reading in the green zone An adolescent who has meningitis and reports a sensitivity to lights and noise
A school-age child who has sickle cell anemia and reports decreased vision in the left eye When using the urgent vs. nonurgent approach to client care, the nurse should determine the priority finding is a report of decreased vision in the left eye. This finding indicates that the child is experiencing a vaso-occlusive crisis and should be reported to the provider immediately. Therefore, the nurse should see this child first.
A nurse in an emergency department is caring for a school-age child who is experiencing an anaphylactic reaction. Which of the following is the priority action by the nurse? Elevate the head of the child's bed. Insert a large bore IV catheter for the child. Determine the allergen that caused the child's reaction. Administer epinephrine IM to the child.
Administer epinephrine IM to the child. When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority action is administering epinephrine IM to the child. During an anaphylactic reaction, histamine release causes bronchoconstriction and vasodilation. This is an emergency because ultimately this causes decreased blood return to the heart.
A nurse is preparing to administer an immunization to a 4-year-old child. Which of the following actions should the nurse plan to take? Place the child in a prone position for the immunization. Request that the child's caregiver leave the room during the immunization. Administer the immunization using a 24-gauge needle. Inject the immunization slowly after aspirating for 3 seconds.
Administer the immunization using a 24-gauge needle. The nurse should administer an immunization for a 4-year-old child using a 22- to 25- gauge needle to minimize the amount of pain the child experiences.
A nurse is assessing a 3-year-old toddler at a well-child visit. Which of the following manifestations should the nurse report to the provider? Blood pressure 90/50 mm Hg Respiratory rate 45/min Weight 14.5 kg (32 lb) Heart rate 110/min
Respiratory rate 45/min The nurse should identify that a respiratory rate of 45/min is above the expected reference range of 20 to 25/min for a 3-year-old toddler and can indicate respiratory dysfunction and acute respiratory distress. Therefore, the nurse should report this finding to the provider
A nurse is interviewing the parent of an 18-month-old toddler during a well-child visit. The nurse should identify that which of the following findings indicates a need to assess the toddler for hearing loss? The toddler has a vocabulary of 25 words. The toddler developed a mild rash following a recent varicella immunization. The toddler's Moro reflex is absent. The toddler received tobramycin during a hospitalization 2 weeks ago.
The toddler received tobramycin during a hospitalization 2 weeks ago. The nurse should identify tobramycin as an aminoglycoside, which is an ototoxic medication that can cause mild to moderate hearing loss, and should assess the toddler for a hearing impairment.
A nurse is teaching the parent of an infant who has a Pavlik harness for the treatment of developmental dysplasia of the hip. The nurse should identify that which of the following statements by the parent indicates an understanding of the teaching? "I should remove the harness at night to allow my infant to stretch her legs." "I will need to adjust the straps on the harness once each week." "I should apply baby powder to my infant's skin twice daily." "I will place my infant's diapers under the harness straps."
"I will place my infant's diapers under the harness straps." To prevent soiling of the harness, the parent should apply the infant's diaper under the straps.
A nurse is providing discharge teaching to the parent of a child who is 1 week postoperative following a cleft palate repair. For which of the following members of the interprofessional team should the nurse initiate a referral? Occupational therapist Speech therapist Respiratory therapist Physical therapist
Speech therapist The nurse should initiate a referral for a speech therapist for a child who is postoperative following a cleft palate repair. A child who has a cleft palate will require speech therapy immediately following the repair to support speech development and future articulation.
A nurse on a pediatric unit is admitting a preschooler. Vital Signs 0715: Temperature 38.3° C (100.9° F)Heart rate 126/minRespiratory rate 26/minPulse oximeter 97% Physical Examination 0715:Guardians report that the child has been tired lately and has been experiencing a sore throat and fever. Child is tolerating sips of liquids, but is refusing solid foods. Guardians report that the child is voiding dark yellow urine.0730:Child is alert and responsive to verbal stimuli. Mucous membranes are dry and sticky. Skin turgor without tenting. Tonsils enlarged and erythematous. Respirations are regular and non-labored. No accessory muscle use noted. Lungs clear anterior and posterior bilaterally. Point of maximum intensity (PMI) in the left mid-clavicular line 4th intercostal space. Heart rate is regular without murmurs, gallops, or rubs. Radial and pedal pulse 2+ bilaterally. Capillary refill greater than 2 seconds. Abdomen flat and non-distended. Bowel sounds active in all four quadrants. Extremities are warm and dry to touch. Diagnostic Results 0900: Mononucleosis rapid test: positive (negative) After reviewing the information in the medical record, the nurse should identify that the child i
Dropdown 1: Splenomegaly is correct. The child's positive mononucleosis rapid test result indicates the presence of infectious mononucleosis, a condition caused by the Epstein-Barr virus. Therefore, the nurse should identify that the child is at risk for developing splenomegaly, a common complication of infectious mononucleosis. Dropdown 2: Positive mononucleosis rapid test is correct. The child's positive mononucleosis rapid test result indicates the presence of infectious mononucleosis, a condition caused by the Epstein-Barr virus. Therefore, the nurse should identify that the child is at risk for developing splenomegaly, a common complication of infectious mononucleosis.
A nurse in an emergency department is caring for a 4-year-old child whowas rescued from a home fire by emergency medical services (EMS). History and Physical 4-year-old child was in a house fire and rescued by EMS. Child has partial-thickness and full-thickness burns on their left arm, hand, anterior neck, and upper left side of the anterior chest. Total body surface area (TBSA) estimated to be 18%. Child is awake and crying. Lungs are clear bilaterally. Has a non-productive cough. Graphic Record Temperature 37.7° C (99.9° F)Heart rate 150/minRespiratory rate 32/minBlood pressure 100/52 mm HgSaO2 89% on room air Which of the following potential provider prescriptions should the nurse identify as anticipated or contraindicated? For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the child.
Apply sterile gauze soaked with cool 0.9% sodium chloride to the burn areas is contraindicated. Applying sterile gauze soaked with cool 0.9% sodium chloride to a child who has 18% TBSA might cause hypothermia. The nurse should cover the burn with a clean, dry cloth to prevent contamination and hypothermia. Insert an indwelling urinary catheter is anticipated. Inserting an indwelling urinary catheter is essential and allows for accurate measurement of urine output. Urine output is an indicator of the fluid status of the child. A child who has major burns will lose a significant amount of fluid due to increased capillary permeability, which increases the risk for hypovolemic shock. It is important to maintain accurate hourly I&O to manage fluid replacement. Provide 100% oxygen via face mask is anticipated. Upon admission to the emergency department, the nurse should recognize the need to provide 100% oxygen via face mask as an essential prescription. The child's SaO2 is below the expected reference range and their respiratory rate is increased. Weigh the child is anticipated. The nurse should recognize the need to weigh the child as essential. Children of the same age weigh different amounts. The amount of fluid resuscitation and medication a pediatric patient receives is based on their weight.
The nurse is providing discharge teaching to the child and their parent 36 days after admission. Exhibit 1 Nurses' Notes 0900: Home care consultation and supply delivery arrangements completed by the child's case manager. 1400: Provided discharge teaching to the parent and child regarding medications, skin and wound care, and psychosocial needs. Parent verbalized understanding of teaching. Select 6 statements by the parent that indicate an understanding of the discharge teaching. "I will give my child hydroxyzine to prevent bacterial infection." "I should apply a moisturizer to the scar tissue." "I will use a measured spoon or medicine cup to give my child hydroxyzine." "I can give my child hydroxyzine every 6 hours as needed." "Puppet play can be helpful for my child." "I should avoid giving hydroxyzine at bedtime." "I will avoid massaging the scar tissue." "My child is too young to be concerned about their body image." "I need to assess for any redness or open skin areas before applying my child's left arm splint." "My child will need to use a compression garment to decrease blood supply to the scarred tissue."
"I should apply a moisturizer to the scar tissue" is correct. Frequent application of a non-perfume moisturizer should be applied to the scar tissue to help reduce itching the child might experience. "I will use a measured spoon or medicine cup to give my child hydroxyzine" is correct. All liquid medications should be administered with a measured spoon or cup to provide an accurate amount of the prescribed dose of medication. "I can give my child hydroxyzine every 6 hours as needed" is correct. Hydroxyzine is administered every 6 to 8 hr each day as needed. "Puppet play can be helpful for my child" is correct. Preschoolers engage in imaginative play. The use of puppets will encourage the child to express their feelings through imaginary play. "I need to assess for any redness or open skin areas before applying my child's left arm splint" is correct. It is important that the child's skin be assessed for redness, open areas, or blisters prior to putting on a splint. The splint is used to prevent contractures of the extremities and promote normal alignment during the healing process. Because the splint might be worn for a long period of time, the child's growth might cause the splint to not fit properly and can cause a pressure injury. "My child will need to use a compression garment to decrease blood supply to the scarred tissue" is correct. Using a compression garment on the scar tissue decreases the blood supply to avoid nourishing the hypertrophic tissue. It also forces the collagen into a more normal alignment. Compression garments are worn during the healing of the burned tissue and should be worn as much as possible.
A nurse in an emergency department is caring for a 4-year-old child who was rescued from a home fire by emergency medical services (EMS History and Physical 4-year-old child was in a house fire and rescued by EMS. Child has partial-thickness and full-thickness burns on their left arm, hand, anterior neck, and upper left side of the anterior chest. Total body surface area (TBSA) estimated to be 18%. Child is awake and crying. Lungs are clear bilaterally. Has a non-productive cough. Graphic Record Temperature 37.7° C (99.9° F)Heart rate 150/minRespiratory rate 32/minBlood pressure 100/52 mm HgSaO2 89% on room air The nurse should identify that which of the following findings require immediate follow-up? Select the 3 findings that require immediate follow-up. Child is awake and crying Partial- and full-thickness burns to the left upper anterior chest and anterior neck Non-productive cough SaO2 89% on room air Heart rate 150/min Temperature 37.7° C (99.9° F) Blood pressure 100/52 mm Hg
. Partial- and full-thickness burns to the left upper anterior chest and anterior neck is correct. Airway, breathing, and circulation are the immediate concerns. Burns to the chest and neck require immediate follow-up due to a concern for inhalation injury. In addition, the edema of the tissue in the neck can compromise the airway and severe burns to the chest can impede the child's ability to expand their chest during inspiration, causing respiratory distress. SaO2 89% on room air is correct. Airway, breathing, and circulation are the immediate concerns. The nurse should immediately follow-up on the low oxygen saturation level. Hypoxia can be a manifestation of respiratory distress or shock. Therefore, this finding needs immediate attention. Heart rate 150/min is correct. Airway, breathing, and circulation are the immediate concerns. The nurse should immediately follow-up on the child's increased heart rate. Tachycardia is a manifestation of shock. Children with major burns can develop hypovolemic shock due to fluid loss.
A nurse on a pediatric unit is caring for a school-age child. Nurses' Notes 0830:Child is alert and responsive to stimuli. Skin is warm and dry. Capillary refill less than 3 seconds. Respirations regular and shallow. Mild intercostal retractions noted. Expiratory wheezes auscultated in the anterior and posterior lung bases. Abdomen is soft, flat, and non-distended.1100:Child appears restless. Moderate intercostal retractions noted. Scattered rhonchi anterior bases with wheezing noted on inhalation and exhalation. Point of maximum intensity (PMI) in the left mid-clavicular line 4th intercostal space. Heart rate is regular without murmurs, gallops, or rubs. Radial and pedal pulse 2+ bilaterally. Vital Signs 0830: Temperature 37.1° C (98.8° F)Heart rate 100/minRespiratory rate 22/minBlood pressure 90/60 mm HgPulse oximetry 97% on 2 L of oxygen via nasal cannula1100: Temperature 37.1° C (98.8° F)Heart rate 110/minRespiratory rate 30/minPulse oximetry 94% on 2 L of oxygen via nasal cannula Diagnostic Results 1200:CBC:Hemoglobin 10 g/dL (10 to 15.5 g/dL)Hematocrit 32% (32% to 44%)WBC count 11,000/mm3 (5,000 to 10,000/mm3)Arterial Blood Gases (ABGs):pH 7.49 (7.35 to 7.45)PCO2 32 mm Hg (35 to 4
Arterial blood gases is correct. The child's arterial blood gases (ABGs) indicate respiratory alkalosis, which is associated with complications of asthma, such as hyperventilation and hypoxia. Therefore, the nurse should report these findings to the provider. WBC count is correct. The child's WBC count is above the expected reference range, which could be an indication of infection or inflammation. Therefore, the nurse should report this finding to the provider. Oxygen saturation level is correct. The child's oxygen saturation level has decreased below the expected reference range despite the use of supplemental oxygen. Therefore, the nurse should report this finding to the provider. Respiratory assessment is correct. The child's respiratory assessment indicates increased respiratory distress, as evidenced by the presence of tachypnea, retractions, and increased wheezing. Therefore, the nurse should report these findings to the provider.