4307 exam 3

a. 5mm

A nurse is interpreting the results of a tuberculin skin test (TST) on an adolescent who is HIV positive. Which induration size indicates a positive result 48 to 72 hours after the test? a. 5mm b. 10 mm c. 15 mm d. 20 mm

a. Cognition b. Dexterity d. Range of motion e. Vision

A nurse is planning discharge teaching on tracheostomy care for an older client. What factors does the nurse need to assess before teaching this particular client? (Select all that apply.) a. Cognition b. Dexterity c. Hydration d. Range of motion e. Vision

a. Captopril (Capoten)

A nurse is preparing to administer an angiotensin-converting enzyme (ACE) inhibitor. Which drug would the nurse administer? a. Captopril (Capoten) b. Furosemide (Lasix) c. Spironolactone (Aldactone) d. Chlorothiazide (Diuril)

c. Tying a square knot at the back of the neck

A nurse is providing tracheostomy care. What action by the nurse requires intervention by the charge nurse? a. Holding the device securely when changing ties b. Suctioning the client first if secretions are present c. Tying a square knot at the back of the neck d. Using half-strength peroxide for cleansing

a. Absorptive atelectasis b. Combustion c. Dried mucous membranes e. Toxicity

A nurse is teaching a client about possible complications and hazards of home oxygen therapy. About which complications does the nurse plan to teach the client? (Select all that apply.) a. Absorptive atelectasis b. Combustion c. Dried mucous membranes d. Oxygen-induced hyperventilation e. Toxicity

a. Hypertension b. Stroke c. Weight gain d. Diabetes e. Cognitive deficits f. Pulmonary disease

A nurse is teaching a community group about the long-term effects of untreated sleep apnea. What information does the nurse include? (Select all that apply.) a. Hypertension b. Stroke c. Weight gain d. Diabetes e. Cognitive deficits f. Pulmonary disease

b. Determine if the client can switch to a nasal cannula during the meal

A client is wearing a Venturi mask to deliver oxygen and the dinner tray has arrived. What action by the nurse is best? a. Assess the client's oxygen saturation and, if normal, turn off the oxygen. b. Determine if the client can switch to a nasal cannula during the meal. c. Have the client lift the mask off the face when taking bites of food. d. Turn the oxygen off while the client eats the meal and then restart it.

b. The client has joined a book club that meets at the library.

A client with a new tracheostomy is being seen in the oncology clinic. What finding by the nurse best indicates that goals for the nursing diagnosis Impaired Self-Esteem are being met? a. The client demonstrates good understanding of stoma care. b. The client has joined a book club that meets at the library. c. Family members take turns assisting with stoma care. d. Skin around the stoma is intact without signs of infection.

c. Assist the client to choose a communication method.

A nurse cares for a client who is scheduled for a total laryngectomy. Which action should the nurse take prior to surgery? a. Assess airway patency, breathing, and circulation. b. Administer prescribed intravenous pain medication. c. Assist the client to choose a communication method. d. Ambulate the client in the hallway to assess gait.

a. Apply water-soluble ointment to nares and lips.

A client is receiving oxygen at 4 liters per nasal cannula. What comfort measure may the nurse delegate to unlicensed assistive personnel (UAP)? a. Apply water-soluble ointment to nares and lips. b. Periodically turn the oxygen down or off. c. Remove the tubing from the client's nose. d. Turn the client every 2 hours or as needed.

b. 21%

A nurse caring for a client removes the client's oxygen as prescribed. The client is now breathing what percentage of oxygen in the room air? a. 14% b. 21% c. 28% d. 31%

b. Ensure that informed consent is on the chart.

A client is scheduled to have a tracheostomy placed in an hour. What action by the nurse is the priority? a. Administer prescribed anxiolytic medication. b. Ensure that informed consent is on the chart. c. Reinforce any teaching done previously. d. Start the preoperative antibiotic infusion.

c. 90 to 110

A 6-month-old infant is receiving digoxin (Lanoxin). The nurse would notify the practitioner and withhold the medication if the apical pulse is less than beats/min. a. 60 b. 70 c. 90 to 110 d. 110 to 120

a. Assess the client's oxygen saturation.

A client has a tracheostomy that is 3 days old. Upon assessment, the nurse notes that the client's face is puffy and the eyelids are swollen. What action by the nurse takes best? a. Assess the client's oxygen saturation. b. Notify the Rapid Response Team. c. Oxygenate the client with a bag-valve-mask. d. Palpate the skin of the upper chest.

b. Measure and compare cuff pressures.

A client has a tracheostomy tube in place. When the nurse suctions the client, food particles are noted. What action by the nurse is best? a. Elevate the head of the client's bed. b. Measure and compare cuff pressures. c. Place the client on NPO status. d. Request that the client have a swallow study.

a. Create a communication system. d. Try loose-fitting shirts with collars. e. Wear fashionable scarves.

A client is being discharged home after having a tracheostomy placed. What suggestions does the nurse offer to help the client maintain self-esteem? (Select all that apply.) a. Create a communication system. b. Don't go out in public alone. c. Find hobbies to enjoy at home. d. Try loose-fitting shirts with collars. e. Wear fashionable scarves.

a. The client does not allow smoking in the house. b. Electrical cords are in good working order. c. Flammable liquids are stored in the garage.

A home health nurse is visiting a new client who uses oxygen in the home. For which factors does the nurse assess when determining if the client is using the oxygen safely? (Select all that apply.) a. The client does not allow smoking in the house. b. Electrical cords are in good working order. c. Flammable liquids are stored in the garage. d. Household light bulbs are the fluorescent type. e. The client does not have pets inside the home.

d. The trachea is shifted toward the opposite side of the neck.

A nurse assesses a client after a thoracentesis. Which assessment finding warrants immediate action? a. The client rates pain as a 5/10 at the site of the procedure. b. A small amount of drainage from the site is noted. c. Pulse oximetry is 93% on 2 L of oxygen. d. The trachea is shifted toward the opposite side of the neck.

c. Client has reduced breath sounds—nurse calls primary health care provider immediately.

A nurse assesses a client after an open lung biopsy. Which assessment finding is matched with the correct intervention? a. Client reports being dizzy—nurse calls the Rapid Response Team. b. Client's heart rate is 55 beats/min—nurse withholds pain medication. c. Client has reduced breath sounds—nurse calls primary health care provider immediately. d. Client's respiratory rate is 18 breaths/min—nurse decreases oxygen flow rate.

a. Collect the nasal drainage on a piece of filter paper.

A nurse assesses a client who has a nasal fracture. The client reports constant nasal drainage, a headache, and difficulty with vision. Which action should the nurse take next? a. Collect the nasal drainage on a piece of filter paper. b. Encourage the client to blow his or her nose. c. Perform a test focused on a neurologic examination. d. Palpate the nose, face, and neck.

a. Stridor d. Ecchymosis behind the ear

A nurse assesses a client who has facial trauma. Which assessment findings require immediate intervention? (Select all that apply.) a. Stridor b. Nasal stuffiness c. Edema of the cheek d. Ecchymosis behind the ear e. Eye pain f. Swollen chin

a. Observe for clear drainage. b. Assess for signs of bleeding. c. Watch the client for frequent swallowing. d. Ask the client to open his or her mouth.

A nurse assesses a client who is 6 hours post-surgery for a nasal fracture and has nasal packing in place. Which actions should the nurse take? (Select all that apply.) a. Observe for clear drainage. b. Assess for signs of bleeding. c. Watch the client for frequent swallowing. d. Ask the client to open his or her mouth. e. Administer a nasal steroid to decrease edema. f. Change the nasal packing.

a. Visual hallucinations d. Manic behavior

A nurse assesses a client who is prescribed varenicline for smoking cessation. Which signs or symptoms would the nurse identify as adverse effects of this medication? (Select all that apply.) a. Visual hallucinations b. Tachycardia c. Decreased cravings d. Manic behavior e. Increased thirst f. Orangish urine

b. New-onset cough d. Tachypnea e. Pain with respirations

A nurse assesses a client who is recovering from a thoracentesis. Which assessment findings would alert the nurse to a potential pneumothorax? (Select all that apply.) a. Bradycardia b. New-onset cough c. Purulent sputum d. Tachypnea e. Pain with respirations f. Rapid, shallow respirations

d. occupation and hobbies

A nurse assesses a client's respiratory status. Which information is most important for the nurse to obtain? a. Average daily fluid intake. b. Neck circumference. c. height and weight d. occupation and hobbies

c. A 55-year-old woman who is 50 pounds overweight

A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for development of obstructive sleep apnea? a. A 26-year-old woman who is 8 months pregnant b. A 42-year-old man with gastroesophageal reflux disease c. A 55-year-old woman who is 50 pounds overweight d. A 73-year-old man with type 2 diabetes mellitus

a. Document the findings.

A nurse auscultates a harsh hollow sound over a client's trachea and larynx. What action would the nurse take first? a. Document the findings. b. Administer oxygen therapy. c. Position the client in high-Fowler position. d. Administer prescribed albuterol. ANS: A

c. Explain that soreness is normal and will improve in a couple days.

A nurse cares for a client after radiation therapy for lung cancer. The client reports a sore throat. Which action should the nurse take first? a. Ask the client to gargle with mouthwash containing lidocaine. b. Administer prescribed intravenous pain medications. c. Explain that soreness is normal and will improve in a couple days. d. Assess the client's neck for redness and swelling.

c. Assess the client's gag reflex before giving any food or water.

A nurse cares for a client who had a bronchoscopy 2 hours ago. The client asks for a drink of water. What action would the nurse take next? a. Call the primary health care provider and request food and water for the client. b. Provide the client with ice chips instead of a drink of water. c. Assess the client's gag reflex before giving any food or water. d. Let the client have a small sip to see whether he or she can swallow.

b. "This is normal after surgery. What types of food do you like to eat?"

A nurse cares for a client who had a partial laryngectomy 10 days ago. The client states that all food tastes bland. How should the nurse respond? a. "I will consult the speech therapist to ensure you are swallowing properly." b. "This is normal after surgery. What types of food do you like to eat?" c. "I will ask the dietitian to change the consistency of the food in your diet." d. "Replacement of protein, calories, and water is very important after surgery."

a. Assess the client for obstructive sleep apnea.

A nurse cares for a client who has hypertension that has not responded well to several medications. The client states compliance is not an issue. What action would the nurse take next? a. Assess the client for obstructive sleep apnea. b. Arrange a home sleep apnea test. c. Encourage the client to begin exercising. d. Schedule a polysomnography Btestb

d. Make sure the string is taped to the client's cheek and assess the airway

A nurse cares for a client who has packing inserted for posterior nasal bleeding. Which action should the nurse take first? a. Assess the client's pain level. b. Keep the client's head elevated. c. Teach the client about the causes of nasal bleeding. d. Make sure the string is taped to the client's cheek and assess the airway

a. "I held the client's morning bronchodilator medication." d. "I advised the client not to smoke for 6 hours prior to the test." e. "The client is alert and can follow your commands."

A nurse collaborates with a respiratory therapist to complete pulmonary function tests (PFTs) for a client. Which statements would the nurse include in communications with the respiratory therapist prior to the tests? (Select all that apply.) a. "I held the client's morning bronchodilator medication." b. "The client is ready to go down to radiology for this examination." c. "Physical therapy states the client can run on a treadmill." d. "I advised the client not to smoke for 6 hours prior to the test." e. "The client is alert and can follow your commands."

d. Stay with the client and have someone else call the primary health care provider immediately

A nurse is assessing a client who has a tracheostomy. The nurse notes that the tracheostomy tube is pulsing with the heartbeat as the client9s pulse is being taken. No other abnormal findings are noted. What action by the nurse is most appropriate? a. Call the operating room to inform them of a pending emergency case. b. No action is needed at this time; this is a normal finding in some clients. c. Remove the tracheostomy tube; ventilate the client with a bag-valve-mask. d. Stay with the client and have someone else call the primary health care provider immediately

d. Airway patency

A nurse is assessing a client who has suffered a nasal fracture. Which assessment should the nurse perform first? a. Facial pain b. Vital signs c. Bone displacement d. Airway patency

b. Obtain pulse oximetry reading

A nurse is assessing a client who is recovering from a lung biopsy. The client's breath sounds are absent. While another nurse calls the Rapid Response Team, what action by the nurse takes is most important? a. Take a full set of vital signs. b. Obtain pulse oximetry reading. c. Ask the patient about hemoptysis. d. Inspect the biopsy site.

a. Investigate all history of known exposures. b. Determine if breathing problems are worse at work. c. Ask the client what type of heating is in the home. d. Gather details about the geographic location of the client's home. e. Have client list all previous jobs and work experiences. f.Assess what hobbies the client and family enjoy.

A nurse is assessing a client's history of particular matter exposure. What questions are consistent with the I PREPARE tool? (Select all that apply.) a. Investigate all history of known exposures. b. Determine if breathing problems are worse at work. c. Ask the client what type of heating is in the home. d. Gather details about the geographic location of the client's home. e. Have client list all previous jobs and work experiences. f.Assess what hobbies the client and family enjoy.

a. A 24-year-old with a traumatic brain injury c. A 58-year-old at risk for aspiration following radiation therapy d. A 66-year-old who is a quadriplegic and has a sacral ulcer e. An 80-year-old who is aphasic after a cerebral vascular accident

A nurse is assessing clients on a rehabilitation unit. Which clients are at greatest risk for asphyxiation related to inspissated oral and nasopharyngeal secretions? (Select all that apply.) a. A 24-year-old with a traumatic brain injury b. A 36-year-old who fractured his left femur c. A 58-year-old at risk for aspiration following radiation therapy d. A 66-year-old who is a quadriplegic and has a sacral ulcer e. An 80-year-old who is aphasic after a cerebral vascular accident

b. Intact skin behind the ears

A nurse is caring for a client using oxygen while in the hospital. What assessment finding indicates that outcomes for client safety with oxygen therapy are being met? a. 100% of meals being eaten by the client b. Intact skin behind the ears c. The client understanding the need for oxygen d. Unchanged weight for the past 3 days

c. Client is able to swallow own secretions without drooling.

A nurse is caring for a client who had a modified uvulopalatopharyngoplasty (modUPPP) earlier in the day for obstructive sleep apnea. Which assessment finding indicates that a priority goal has been met? a. Client reports pain is controlled satisfactorily with analgesic regime. b. Client does not have foul odor to the breath or beefy red mucus membranes. c. Client is able to swallow own secretions without drooling. d. Clients vital signs are within normal parameters.

a. Applying water-soluble lip balm to the client's lips d. Reminding the client to cough and deep breathe often

A nurse is caring for a client who has a tracheostomy tube. What actions may the nurse delegate to unlicensed assistive personnel (UAP)? (Select all that apply.) a. Applying water-soluble lip balm to the client's lips b. Ensuring the humidification provided is adequate c. Performing oral care with alcohol-based mouthwash d. Reminding the client to cough and deep breathe often e. Suctioning excess secretions through the tracheostomy

d. Validate that informed consent has been given by the client.

A nurse is caring for a client who is scheduled to undergo a thoracentesis. Which intervention would the nurse complete prior to the procedure? a. Measure oxygen saturation before and after a 12-minute walk. b. Verify that the client understands all possible complications. c. Explain the procedure in detail to the client and the family. d. Validate that informed consent has been given by the client.

b. Notify the Rapid Response Team.

A nurse is caring for a client who received benzocaine spray prior to a recent bronchoscopy. The client presents with continuous cyanosis even with oxygen therapy. What action would the nurse take next? a. Administer an albuterol treatment. b. Notify the Rapid Response Team. c. Assess the client's peripheral pulses. d. Obtain blood and sputum cultures.

b. Assessing the chest tube and drainage device for correct settings c. Administering prescribed doses of antibiotics e. Monitoring for need of supplemental oxygen

A nurse is caring for a school-age child with left unilateral pneumonia, pleural effusion, and a chest tube connected to closed chest drainage. Which interventions would the nurse implement when caring for this child? (Select all that apply.) a. Manual suctioning of the chest tube every shift b. Assessing the chest tube and drainage device for correct settings c. Administering prescribed doses of antibiotics d. Clamping the chest tube when child ambulates e. Monitoring for need of supplemental oxygen

a. Applying suction while inserting the catheter

A nurse is demonstrating suctioning a tracheostomy during the annual skills review. What action by the student demonstrates that more teaching is needed? a. Applying suction while inserting the catheter b. Preoxygenating the client prior to suctioning c. Suctioning for a total of three times if needed d. Suctioning for only 10 to 15 seconds each time

b. "Do you have any chronic breathing problems?"

A nurse observes that a client's anteroposterior (AP) chest diameter is the same as the lateral chest diameter. Which question would the nurse ask the client in response to this finding? a. "Are you taking any medications or herbal supplements?" b. "Do you have any chronic breathing problems?" c. "How often do you perform aerobic exercise?" d. "What is your occupation and what are your hobbies?"

c. Maintain a nonjudgmental attitude to avoid causing the client to feel guilty.

A nurse obtains the health history of a client who is recently diagnosed with lung cancer and identifies that the client has a 60-pack-year smoking history. Which action is most important for the nurse to take when interviewing this client? a. Tell the client that he or she needs to quit smoking to stop further cancer development. b. Encourage the client to be completely honest about both tobacco and marijuana use. c. Maintain a nonjudgmental attitude to avoid causing the client to feel guilty. d. Avoid giving the client false hope regarding cancer treatment and prognosis.

a. Assistance with activities of daily living

A nurse plans care for a client who is experiencing dyspnea and must stop multiple times when climbing a flight of stairs. Which intervention would the nurse include in this client's plan of care? a. Assistance with activities of daily living b. Physical therapy activities every day c. Oxygen therapy at 2 L per nasal cannula d. Complete bedrest with frequent repositioning

b. Verify that the informed consent was obtained. c. Document the client's allergies d. Review laboratory results. f. Monitor the client for at least 24 hours afterwards.

A nurse prepares a client who is scheduled for a bronchoscopy with transbronchial biopsy procedure at 9:00 AM (0900). What actions would the nurse take? (Select all that apply.) a. Provide a clear liquid breakfast. b. Verify that the informed consent was obtained. c. Document the client's allergies d. Review laboratory results. e. Hold the client's bronchodilator. f. Monitor the client for at least 24 hours afterwards.

b. "Make sure you clean the humidifier to prevent infection."

A nurse teaches a client to use a room humidifier after a laryngectomy. Which statement should the nurse include in this client's teaching? a. "Add peppermint oil to the humidifier to relax the airway." b. "Make sure you clean the humidifier to prevent infection." c. "Keep the humidifier filled with water at all times." d. "Use the humidifier when you sleep, even during daytime naps."

b. Swallow twice while bearing down.

A nurse teaches a client who had a supraglottic laryngectomy. Which technique would the nurse teach the client to prevent aspiration? a. Tilt the head back as far as possible when swallowing. b. Swallow twice while bearing down. c. Breathe slowly and deeply while swallowing. d. Keep the head very still and straight while swallowing

a. "You will need to cut the wires if you start vomiting." b. "Eat six soft or liquid meals each day while recovering." c. "Irrigate your mouth every 2 hours to prevent infection." d. "Sleep in a semi-Fowler's position after the surgery."

A nurse teaches a client who is being discharged after a fixed centric occlusion for a mandibular fracture. Which statements should the nurse include in this client's teaching? (Select all that apply.) a. "You will need to cut the wires if you start vomiting." b. "Eat six soft or liquid meals each day while recovering." c. "Irrigate your mouth every 2 hours to prevent infection." d. "Sleep in a semi-Fowler's position after the surgery." e. "Gargle with mouthwash that contains Benadryl once a day."

a. "Find an activity that you enjoy and will keep your hands busy." d. "Drink at least eight glasses of water each day." e. "Make a list of reasons you want to stop smoking." f. "Set a quit date and stick to it."

A nurse teaches a client who is interested in smoking cessation. Which statements would the nurse include in this client's teaching? (Select all that apply.) a. "Find an activity that you enjoy and will keep your hands busy." b. "Keep snacks like potato chips on hand to nibble on." c. "Identify a consequence for yourself in case you backslide." d. "Drink at least eight glasses of water each day." e. "Make a list of reasons you want to stop smoking." f. "Set a quit date and stick to it."

c. "Smoking while taking this medication will increase your risk of a stroke."

A nurse teaches a client who is prescribed nicotine replacement therapy. Which statement would the nurse include in this client's teaching? a. "Make a list of reasons why smoking is a bad habit." b. "Rise slowly when getting out of bed in the morning." c. "Smoking while taking this medication will increase your risk of a stroke." d. "Stopping this medication suddenly increases your risk for a heart attack."

a. Bronchitis

A school-age child had an upper respiratory tract infection for several days and then began having a persistent dry, hacking cough that was worse at night. This is most suggestive of which diagnosis? a. Bronchitis b. Bronchiolitis c. Viral-induced asthma d. Acute spasmodic laryngitis

b. Poor feeding c. Rapid weight gain d. Tachypnea

The nurse is conducting discharge teaching about signs and symptoms of heart failure to parents of an infant with cardiomyopathy. Which signs and symptoms would the nurse include? (Select all that apply.) a. Warm flushed extremities b. Poor feeding c. Rapid weight gain d. Tachypnea

a. Assess the client's lung sounds.

An assistive personnel (AP) was feeding a client with a tracheostomy. Later that evening, the UAP reports that the client had a coughing spell during the meal. What action by the nurse is best? a. Assess the client's lung sounds. b. Assign a different AP to the client. c. Report the AP to the manager. d. Request thicker liquids for meals

d. Sweat chloride test

Cystic fibrosis (CF) is suspected in a toddler. Which test aids in establishing this diagnosis? a. Bronchoscopy b. Serum calcium c. Urine creatinine d. Sweat chloride test

a. Avoid using for more than 3 days.

Decongestant nose drops are prescribed for a 10-month-old infant with an upper respiratory tract infection. Instructions for nose drops would include which action? a. Avoid using for more than 3 days. b. Keep drops to use again for nasal congestion. c. Administer drops until nasal congestion subsides. d.Administer drops only when symtomatic.

a. It decreases edema.

The nurse is preparing to administer a dose of digoxin (Lanoxin) to a child in heart failure (HF). Which is a beneficial effect of administering digoxin (Lanoxin)? a. It decreases edema. b. It decreases cardiac output. c. It increases heart size. d. It increases venous pressure.

b. Complete obstruction

Examining the child's throat who has epiglottitis by using a tongue depressor might precipitate which symptom or condition? a. Inspiratory stridor b. Complete obstruction c. Sore throat d. Respiratory tract infection

b. A viral infection

In addition to allergens, which other substance or condition has a significant role in the development and expression of asthma? a. Medications b. A viral infection c. Exposure to cold air d. A diet high in protein

a. Cluster care to conserve energy d. Administration of antibiotics e. Provide adequate hydration

Nursing care of the child with a bacterial pneumonia includes which interventions? (Select all that apply.) a. Cluster care to conserve energy b. Round-the-clock administration of antitussive agents c. Strict intake and output to avoid congestive heart failure d. Administration of antibiotics e. Provide adequate hydration

b. Monitor vital signs as frequently as every 15 minutes. c. Assess the affected extremity for temperature and color. d. Check pulses below the catheterization site for equality and symmetry.

Nursing interventions for the child following a venous cardiac catheterization would include which actions? (Select all that apply.) a. Allow ambulation as tolerated. b. Monitor vital signs as frequently as every 15 minutes. c. Assess the affected extremity for temperature and color. d. Check pulses below the catheterization site for equality and symmetry. e. Remove pressure dressing after 4 hours. f. Keep affected extremity straight for 10 to 12 hours.

d. Pancreatic enzymes can be swallowed whole or sprinkled on a small amount of food taken at the beginning of a meal.

Pancreatic enzymes are administered to the child with cystic fibrosis (CF). What nursing considerations should be included? a. Do not administer pancreatic enzymes if the child is receiving antibiotics. b. Decrease dose of pancreatic enzymes if the child is having frequent, bulky stools. c. Administer pancreatic enzymes between meals if at all possible. d. Pancreatic enzymes can be swallowed whole or sprinkled on a small amount of food taken at the beginning of a meal.

a. "We will avoid second hand smoke." d. "A conjugate vaccine may be administered." e. "We will adminster medications as prescribed."

Parents have understood teaching about prevention of childhood otitis media if they make which statement? (Select all that apply.) a. "We will avoid second hand smoke." b. "Breastfeeding will be discontinued after 4 months of age." c. "We will place the child flat right after feedings." d. "A conjugate vaccine may be administered." e. "We will adminster medications as prescribed."

a. The child needs opportunities to play with peers.

Parents of a 3-year-old child with congenital heart disease are afraid to let their child play with other children because of possible overexertion. The nurse's reply would be based on which statement? a. The child needs opportunities to play with peers. b. The child needs to understand that peers' activities are too strenuous. c. Parents can meet all of the child's needs. d. Constant parental supervision is needed to avoid overexertion

b. Vomiting

The nurse is teaching parents about signs of digoxin (Lanoxin) toxicity. Which is a common sign of digoxin toxicity? a. Seizures b. Vomiting c. Bradypnea d. Tachycardia

a. 1

The Heimlich maneuver is recommended for airway obstruction in children older than year(s). a. 1 b. 4 c. 8 d. 12

d. Therapeutic management includes administration of gamma globulin and salicylates (aspirin).

When caring for the child with Kawasaki disease, the nurse would know which information? a. A child's fever is usually responsive to antibiotics within 48 hours. b. The principal area of involvement is the joints. c. The child is very docile through the illness. d. Therapeutic management includes administration of gamma globulin and salicylates (aspirin).

c. After taking antibiotics for 24 hours.

When is it generally recommended that a child with acute streptococcal pharyngitis return to school? a. When sore throat has improved. b. If no complications develop. c. After taking antibiotics for 24 hours. d. After taking antibiotics for 3 days.

a. Staphylococcus aureus d. Viridans streptococci e. Candida albicans

Which are organisms are known to cause bacterial endocarditis? (Select all that apply.) a. Staphylococcus aureus b. Streptococcus hemolyticus c. Staphylococcus albicans d. Viridans streptococci e. Candida albicans

a. Heightened airway reactivity.

The inflammation associated with asthma contributes to which of the following? a. Heightened airway reactivity. b. Decreased resistance in the airway. c. Allergic hypersensitivity. d. Increased viscosity of mucous glad secretions.

d. Inability to speak

The mother of a toddler yells to the nurse, "Help! He is choking to death on his food." The nurse determines that lifesaving measures are necessary based on which symptom? a. Gagging b. Coughing c. Pulse over 100 beats/min d. Inability to speak

c. Immediately increase the flow rate.

The nurse assesses the client using the device pictured below to deliver 50% O2:The nurse finds the mask fits snugly, the skin under the mask and straps is intact, and the flow rate of the oxygen is 3 L/min. What action by the nurse is best? a. Assess the client's oxygen saturation. b. Document these findings in the chart. c. Immediately increase the flow rate. d. Turn the flow rate down to 2 L/min.

b. Potassium

The nurse encourages the family to give a child who is prescribed furosemide (Lasix) foods such as bananas, oranges, and leafy vegetables because they are high in which nutrient? a. Chlorides b. Potassium c. Sodium d. Vitamins

a. Administering penicillin

The nurse is admitting a child with rheumatic fever. Which therapeutic management would the nurse expect to implement? a. Administering penicillin b. Ambulation as tolerated c. Imposing strict bed rest for 4 to 6 weeks d. Administering corticosteroids if chorea develops

a. Ensure contact precautions are implemented. e. Cluster care to encourage adequate rest. f. Place on noninvasive oxygen monitoring for oxygen saturation < 90%.

The nurse is caring for a 10-month-old infant with respiratory syncytial virus (RSV) bronchiolitis. Which intervention would be included in the child's care? (Select all that apply.) a. Ensure contact precautions are implemented. b. Administer antibiotics. c. Administer cough syrup. d. Provide 8 ounces of formula every 4 hours. e. Cluster care to encourage adequate rest. f. Place on noninvasive oxygen monitoring for oxygen saturation < 90%.

a. Notify the surgeon if the child swallows frequently. c. Place the child on the abdomen until fully awake.

The nurse is caring for a 5-year-old child who is scheduled for a tonsillectomy. Which action should the nurse include in the child's postoperative care plan? (Select all that apply.) a. Notify the surgeon if the child swallows frequently. b. Apply a heat collar to the child for pain relief. c. Place the child on the abdomen until fully awake. d. Prepare for oral liquids immediately following procedure. e. Encourage the child to cough frequently.

c. Immediately report this to physician

The nurse is caring for a child after heart surgery. Which would the nurse do if evidence of cardiac tamponade is found? a. Increase analgesia b. Apply warming blankets c. Immediately report this to physician d. Encourage child to cough, turn, and breathe deeply

b. Monitoring pulse oximetry

The nurse is caring for a child with acute respiratory distress syndrome (ARDS) associated with sepsis. Which is the priority nursing intervention? a. Forcing fluids b. Monitoring pulse oximetry c. Instituting seizure precautions d. Encouraging a high-protein diet

a. Administer 100% humidified oxygen.

The nurse is caring for a child with possible carbon monoxide poisoning associated with smoke inhalation. Which treatment is initiated immediately? a. Administer 100% humidified oxygen. b. Monitor arterial blood gases. c. Administer oxygen if respiratory distress develops. d. The child is rushed to endoscopy for a bronchoscopy

d. Apply direct pressure above catheterization site

The nurse is caring for a school-age child who has had a cardiac catheterization, and upon assessment of the leg finds the bandage and bed soaked with blood. Which is the priority nursing action? a. Notify physician b. Apply new bandage with more pressure c. Place the child in Trendelenburg position d. Apply direct pressure above catheterization site

a. Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy

The nurse is conducting a staff in-service on congenital heart defects. Which structural defect constitutes tetralogy of Fallot? a. Pulmonic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy b. Aortic stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy c. Aortic stenosis, atrial septal defect, overriding aorta, left ventricular hypertrophy d. Pulmonic stenosis, ventricular septal defect, aortic hypertrophy, left ventricular hypertrophy

b. Repeated exposure to organisms causes increased immunity.

Which best describes why toddlers have fewer respiratory tract infections as they grow older? a. The amount of lymphoid tissue decreases. b. Repeated exposure to organisms causes increased immunity. c. Viral organisms are less prevalent in the population. d. Secondary infections rarely occur after viral illnesses.

c. Cool extremities d. Confusion e. Narrowing pulse pressure f. Tachypnea

Which clinical manifestation would the nurse expect to see as shock progresses in a child and becomes decompensated shock? (Select all that apply.) a. High blood pressure b. Irritability c. Cool extremities d. Confusion e. Narrowing pulse pressure f. Tachypnea

b. Pharmacotherapy

Which consideration is the most important in managing tuberculosis (TB) in children? a. Skin testing annually b. Pharmacotherapy c. Adequate nutrition d. Adequate hydration

c. Atrial septal defect

Which defect results in increased pulmonary blood flow? a. Pulmonic stenosis b. Tricuspid atresia c. Atrial septal defect d. Transposition of the great arteries

d. Short-acting 2 agonists

Which drug is usually given first in the emergency treatment of an acute, severe asthma episode in a young child? a. Ephedrine b. Theophylline c. Aminophylline d. Short-acting 2 agonists

d. Cardiac valve damage

Which is a serious complication which occurs in more than half of the cases of rheumatic fever? a. Seizures b. Cardiac arrhythmias c. Pulmonary hypertension d. Cardiac valve damage

c. Administer analgesics before the procedure.

Which is an important nursing consideration when chest tubes will be removed from a young child? a. Explain that it is not painful. b. Prepare a Band-Aid for the dressing. c. Administer analgesics before the procedure. d. Expect bright red drainage for several hours after removal.

c. Administer supplemental oxygen before and after suctioning.

Which is an important nursing consideration when suctioning a child who is intubated after cardiac surgery with cardiopulmonary bypass? a. Perform suctioning at least every hour. b. Suction for no longer than 30 seconds at a time. c. Administer supplemental oxygen before and after suctioning. d. Expect symptoms of respiratory distress when suctioning.

b. Prevent dehydration

Which is important to decrease the risk of a cerebrovascular accident in a patient with hypoxemia secondary to a cardiac defect? a. Minimize seizures b. Prevent dehydration c. Promote cardiac output d. Reduce energy expenditure

d. Prevents the return of oxygenated blood to the lungs

Which is the expected outcome from surgical closure of the ductus arteriosus? a. Stops the loss of unoxygenated blood to the systemic circulation b. Decreases the edema in legs and feet c. Increases the oxygenation of blood d. Prevents the return of oxygenated blood to the lungs

b. Increased cardiac output

Which occurs in early septic shock? a. Hypothermia b. Increased cardiac output c. Vasoconstriction d. Angioneurotic edema

a. Osler nodes

Which painful, tender, pea-sized nodules may appear on the pads of the fingers or toes in bacterial endocarditis? a. Osler nodes b. Janeway lesions c. Subcutaneous nodules d. Aschoff nodes

a. If it is present in a child, both parents are carriers of this defective gene.

Which statement, made by the nurse, expresses accurately the genetic implications associated with cystic fibrosis? a. If it is present in a child, both parents are carriers of this defective gene. b. It is inherited as an autosomal dominant trait. c. It is a genetic defect found primarily in non-Caucasian population groups. d. There is a 50% chance that siblings of an affected child also will be affected.

b. Epiglottitis

Which type of croup is always considered a medical emergency? a. Laryngitis b. Epiglottitis c. Spasmodic croup d. Laryngotracheobronchitis (LTB)

a. Contact the provider and prepare for intubation.

While assessing a client who has facial trauma, the nurse auscultates stridor. The client is anxious and restless. Which action should the nurse take first? a. Contact the provider and prepare for intubation. b. Administer prescribed albuterol nebulizer therapy. c. Place the client in high-Fowler's position. d. Ask the client to perform deep-breathing exercises.

a. "What happens when you are exposed to those things? b. "How do you treat these allergies?" d. "I will document this in your record so all so everyone knows." e. "Have you ever been in the hospital after an allergic response?"

While obtaining a client's health history, the client states, "I am allergic to avocados, molds, and grass." Which responses by the nurse are best? (Select all that apply.) a. "What happens when you are exposed to those things? b. "How do you treat these allergies?" c. "When was the last time you ate foods containing avocados?" d. "I will document this in your record so all so everyone knows." e. "Have you ever been in the hospital after an allergic response?" f. "How do manage to avoid grass and mold?"