ATI assessment B peds
A nurse is creating a plan of care for a preschooler who has Wilms' tumor and is scheduled for surgery. Which of the following interventions should the nurse include?
Avoid palpating the abdomen when bathing the child before surgery. MY ANSWER The nurse should avoid palpating the abdomen when bathing the child before surgery because movement of the tumor can cause cancer cells to disseminate to other sites, adjacent and distant to the tumor site. Wrong Refrain from auscultating the child's bowel sounds during the postoperative assessment. Auscultation of the child's bowel sounds to monitor for an obstruction is an important part of the postoperative assessment. Therefore, the nurse should auscultate bowel sounds following the surgery. Encourage the child to play with other children on the unit prior to surgery. The child's risk for injury increases with physical activity. Therefore, the nurse should not encourage the child to play with other children on the unit. Explain to the child that their pain will be managed after the surgery. Telling the child about pain prior to surgery will likely increase their fear and anxiety level. Therefore, the nurse should not explain to the child that pain will be managed after surgery.
A nurse is caring for a 1-month-old infant who is breastfeeding and requires a heel stick. Which of the following actions should the nurse take to minimize the infants pain?
Allow the mother to breastfeed while the sample is being obtained. The nurse should allow the mother to breastfeed the infant prior to or during the procedure. Evidence-based practice indicates breastfeeding or non-nutritive sucking with a pacifier can provide nonpharmacological pain management in infants. Wrong Apply an ice pack to the infant's heel prior to obtaining the sample. The nurse should apply a heating pad to the infant's heel prior to obtaining the sample. This will increase blood flow to the site, which will make the sample easier to obtain. Use a manual lancet to obtain the heel blood sample. The use of a manual lancet should be avoided because it can cause more discomfort. Evidence-based practice recommends using an automatic lancet to obtain heel samples because it is safer and less traumatic. Use a manual lancet to obtain the heel blood sample. The use of a manual lancet should be avoided because it can cause more discomfort. Evidence-based practice recommends using an automatic lancet to obtain heel samples because it is safer and less traumatic.
A nurse is performing hearing screenings for children at a community health fair. Which of the following children should the nurse refer to a provider for a more extensive hearing evaluation?
An 8-month-old infant who is not yet making babbling sounds MY ANSWER The nurse should refer an infant who is not making babbling sounds by the age of 7 months to a provider for a more extensive evaluation of hearing. Wrong A 4-year-old preschooler who prefers playing with others rather than alone The nurse should refer a preschooler who prefers playing alone and avoids interaction with others to a provider for a more extensive evaluation of hearing. A 3-month-old infant who has an exaggerated startle response The nurse should refer infants who are under the age of 4 months and lack a startle response to a provider for a more extensive evaluation of hearing. An 18-month-old toddler who has unintelligible speech The nurse should refer a toddler who does not possess intelligible speech by the age of 24 months to a provider for a more extensive evaluation of hearing.
A nurse is caring for a school-age child who has primary nephrotic syndrome and is taking prednisone. Following 1 week of treatment, which of the following manifestations indicates to the nurse that the medication is effective?
Decreased edema MY ANSWER A child who has nephrotic syndrome can experience edema due to the increased glomerular permeability, which increases protein loss. Prednisone decreases glomerular permeability, which causes fluid to shift from the extracellular spaces, resulting in decreased edema. Wrong Increased abdominal girth The nurse should expect decreased abdominal girth with prednisone therapy. Decreased appetite Increased, rather than decreased, appetite is an expected manifestation of corticosteroid therapy. Increased protein in the urine The nurse should expect decreased protein in the urine with prednisone therapy.
A nurse is caring for a school-age child who has diabetes mellitus and was admitted with a diagnosis of diabetic ketoacidosis. When performing the respiratory assessment, which of the following findings should the nurse expect?
Deep respirations of 32/min MY ANSWER The nurse should expect Kussmaul respirations in a child who has diabetic ketoacidosis. These deep and rapid respirations are the body's attempt to eliminate excess carbon dioxide and achieve a state of homeostasis. Wrong Shallow respirations of 10/min The nurse should expect shallow respirations in a child who has respiratory depression related to opioid administration. However, shallow respirations are not an expected finding in a child who has ketoacidosis. Paradoxic respirations of 26/min The nurse should expect paradoxic respirations in a child who has flail chest. However, paradoxic respirations are not an expected finding in a child who has ketoacidosis. Periods of apnea lasting for 20 seconds The nurse should expect periods of apnea lasting 20 seconds or more in a child who has sleep apnea. However, periods of apnea are not an expected finding in a child who has ketoacidosis.
A nurse is reviewing the dietary choices of an adolescent who has iron deficiency anemia. The nurse should identify that which of the following menu items has the highest amount of nonheme iron?
½ cup raisins The nurse should encourage the adolescent to eat raisins because they contain the highest amount of nonheme iron. Wrong ½ cup whole milk Whole milk does not contain the highest amount of nonheme iron. However, it does contain high amounts of calcium. 1 cup orange juiceMY ANSWEROrange juice does not contain the highest amount of nonheme iron. However, it does contain ascorbic acid, which increases the amount of nonheme iron absorbed by the body. 1 cup raw carrots Raw carrots do not contain the highest amount of nonheme iron.
Cheiloplasty
surgical lip restoration (from Greek: χείλος kheilos - "lip") is the technical term for surgery of the lip usually performed by a plastic surgeon or oral and maxillofacial surgeon.
A nurse is providing discharge teaching to the parents of a 3-month old infant following a cheiloplasty. Which of the following instructions should the nurse include?
"Apply a thin layer of antibiotic ointment on your baby's suture line daily for the next 3 days." The nurse should instruct the parents to apply a thin layer of antibiotic ointment on the infant's suture line daily for 3 days and then continue to apply petroleum jelly to the area for several weeks to promote healing. Wrong "Inspect your baby's tongue for white patches using a tongue depressor every 8 hours." The nurse should instruct the parents to avoid placing objects, such as tongue depressors, in the infant's mouth to prevent injury to the suture line. "Expect your baby to swallow more than usual over the next few days." The nurse should instruct the parents to notify the provider of excessive swallowing because this can indicate bleeding and the infant's swallowing of the blood. "Clean your baby's sutures daily with a mixture of chlorhexidine and water." MY ANSWER The nurse should instruct the parents to clean the infant's sutures with sterile water or diluted hydrogen peroxide.
A nurse is teaching a school-age child and their parent about postoperative care following cardiac catheterization. Which of the following instructions should the nurse include?
"Wait 3 days before taking a tub bath." MY ANSWER The child should keep the site clean and dry for at least 3 days to reduce the risk of infection. Tub baths should be avoided for 3 days to avoid immersion of the incision in water. Wrong "Stay home from school for 1 week following the procedure." The child can attend school the next day but they should avoid strenuous activities to prevent bleeding at the insertion site. "Follow a diet that is low in fiber for 1 week." The child can resume their regular diet after the procedure. "Apply a pressure dressing to the site for 3 days." The parent can remove the pressure dressing the day after the procedure and should apply a new adhesive bandage strip daily to the site for at least the next 2 days.
A nurse in a providers office is caring for a school-age child who has varicella. The parents asks the nurse when their child will no longer be contagious. Which of the following responses should the nurse make?
"When your child's lesions are crusted, usually 6 days after they appear." MY ANSWER The nurse should inform the parent that the child is contagious 1 day prior to lesion eruption and until the vesicles have crusted over, which usually takes about 6 days. Wrong "When your child no longer has an increased temperature." The nurse should inform the parent that an absence of a fever does not indicate the child is no longer contagious. "Three days after you first noticed the rash appear on your child." The nurse should inform the parent that the child will remain contagious longer than 3 days after the rash appears. "Two to three weeks, when your child's lesions completely disappear." The incubation period of varicella is two to three weeks. However, this is not related to the appearance and disappearance of the lesions.
A nurse is teaching the guardian of a 6-month-old infant about teething. Which of the following statements should the nurse make?
"Your baby might pull at their ears when they are teething." The nurse should inform the guardian that teething can result in discomfort for the infant. Therefore, the guardian should look for indications such as pulling on the ears, difficulty sleeping, increased drooling, or increased fussiness. Wrong "Rub your baby's gums with an aspirin to decrease discomfort." The guardian should avoid using aspirin or teething powders due to the risk of aspiration, infection, or irritation of the gum tissues. The nurse should recommend cold teething rings or gently rubbing the infant's gums with a cold cloth to minimize discomfort. "Place a beaded teething necklace around your baby's neck." Necklaces can result in suffocation and choking. Therefore, the nurse should instruct the guardian to avoid placing these on the infant. "Your baby's upper middle teeth will erupt first." MY ANSWER The nurse should inform the guardian that the eruption of an infant's teeth begins with the lower central incisors.
A nurse is discussion organ donation with the parents of a school-age child who has sustained brain death due to a bicycle crash. Which of the following actions should the nurse take first?
Explore the parents' feelings and wishes regarding organ donation. MY ANSWER The first action the nurse should take when using the nursing process is assessment. The nurse should first explore the parents' feelings and wishes regarding organ donation to assist in determining if organ donation is the right choice for the family. Wrong Ask the provider to explain misconceptions of organ donation to the parents. The nurse should ask the provider to explain misconceptions of organ donation to the parents, because it is important that they have accurate information before making a final decision. However, there is another action the nurse should take first. Provide written information to the parents about organ donation. The nurse should provide written information to the parents to enhance their understanding about organ donation. However, there is another action the nurse should take first. Inform the parents that written consent is required prior to organ donation. The nurse should inform the parents that written consent is required prior to organ donation to document that the parents have consented to organ donation and that the provider has addressed any questions or concerns the parents might have. However, there is another action the nurse should take first.
A nurse is monitoring the oxygen saturation level of an infant using pulse oximetry. The nurse should secure the sensor to which of the following areas on the infant?
Great toe MY ANSWER The nurse should secure the sensor to the great toe of the infant and then place a snug-fitting sock on the foot to hold the sensor in place. The nurse should also check the skin under the sensor site frequently for temperature, color, and the presence of a pulse. Wrong Wrist It is important for the sensor to be positioned in the correct area to obtain an accurate reading. The nurse should avoid placing the sensor on the wrist because this placement will result in an inaccurate reading. Index finger The nurse should secure the sensor to the index finger of a child and then use a self-adhering bandage to hold the sensor in place; however, this site is not recommended for pulse oximetry of an infant. Heel It is important for the sensor to be positioned in the correct area to obtain an accurate reading. The nurse should avoid placing the sensor on the heel of the infant's foot because this placement will result in an inaccurate reading.
A nurse in a health department is caring for an emancipated adolescent who has an STI and is unaccompanied by a guardian. Which of the following actions should the nurse take?
Have the adolescent sign a consent form for treatment. MY ANSWER The nurse should identify that an emancipated minor can sign the consent form for treatment of an STI or any other form of medical treatment requiring consent. Wrong Instruct the adolescent to return with a guardian. Adolescents or emancipated minors can provide their own consent for any medical treatment. Obtain consent from the adolescent's guardian over the phone. Adolescents or emancipated minors can provide their own consent for any medical treatment. Treat the adolescent without a consent form. Adolescents or emancipated minors can provide their own consent for any medical treatment.
A nurse is assessing an adolescent who received a sodium polystyrene sulfonate enema. Which of the following findings indicates effectiveness of the medication?
Serum potassium level 4.1 mEq/L MY ANSWER The nurse should monitor the adolescent's serum potassium level following the administration of sodium polystyrene sulfonate. This medication is used to treat hyperkalemia by exchanging sodium ions for potassium ions in the intestine. Therefore, a potassium level within the expected reference range of 3.4 to 4.7 mEq/L indicates the effectiveness of the medication. Wrong Absence of nausea and vomiting Absence of nausea and vomiting indicates effectiveness of an antiemetic medication. Sodium polystyrene sulfonate is an antidote, which exchanges sodium ions in the intestine. Therefore, absence of nausea and vomiting is not an indicator of the medication's effectiveness. Reports experiencing an onset of loose stools within 15 min of administration The nurse should monitor the adolescent for diarrhea because it is an adverse effect of sodium polystyrene sulfonate. Blood pressure 86/52 mm Hg A blood pressure of 86/52 mm Hg is below the expected reference range of 90 to 110 mm Hg systolic and 60 to 80 mm Hg diastolic for an adolescent and does not indicate effectiveness of the medication. The nurse should continue to monitor blood pressure as an indicator of fluid and electrolyte imbalance.
Hypopituitarism
underactive pituitary gland that results in deficiency of one or more pituitary hormones. Symptoms of hypopituitarism depend on what hormone is deficient and may include short height, infertility, intolerance to cold, fatigue, and an inability to produce breast milk.
A nurse is assessing a 6-month-old infant during a well-child visit. Which of the following findings should the nurse report to the provider?
Presence of strabismus MY ANSWER Strabismus, or crossing of the eyes, typically disappears at 3 to 4 months of age. If not corrected early, this can lead to blindness. Therefore, the nurse should report this finding to the provider. Wrong Presence of a central incisor tooth The nurse should recognize that the presence of a central incisor tooth is an expected finding for a 6-month-old infant and is not necessary to report to the provider. Presence of an open anterior fontanel The nurse should recognize that the presence of an open anterior fontanel is an expected finding for a 6-month-old infant and is not necessary to report to the provider. The anterior fontanel generally closes around 12 months of age. Presence of external cerumen The nurse should recognize that the presence of cerumen, which is a soft, yellow-brown waxy substance found in the ear, is an expected finding for a 6-month-old infant and is not necessary to report to the provider.
A nurse is providing teaching to an adolescent about how to manage tinea pedis. Which of the following statements by the adolescent indicates an understanding of the teaching?
"I should wear sandals as much as possible." Sandals allow air to circulate around the feet, decreasing perspiration and eliminating the medium for bacteria and fungus to grow. The nurse should inform the adolescent that wearing sandals, open-toed, or well-ventilated shoes will promote healing of the fungal infection. Wrong "I should buy plastic shoes to wear at the swimming pool." The use of plastic shoes increases the occurrence of tinea pedis. The nurse should instruct the adolescent to avoid wearing plastic shoes. "I should place the permethrin cream between my toes twice daily." Permethrin 5% cream is a scabicide used to treat scabies. This treatment is not indicated for tinea pedis. "I should seal my nonwashable shoes in plastic bags for a couple of weeks." MY ANSWER Sealing nonwashable items in plastic bags for 14 days is a recommended practice for clients who have pediculosis. This practice is not indicated for tinea pedis.
A school nurse is providing an in-service for faculty about improving education for students who have ADHD. Which of the following statements by a faculty member indicates an understanding of the teaching?
"I will teach challenging academic subjects to students who have ADHD in the morning." MY ANSWER Faculty should plan to teach challenging academic subjects in the morning when students who have ADHD are most able to focus and their medication is most likely to be effective. Wrong "I will allow students who have ADHD one rest break throughout the day." Faculty should allow frequent breaks throughout the day for students who have ADHD to modify their learning environment. "I will give students who have ADHD the same amount of time as other students to complete tests." Students who have ADHD should be given additional time to take tests due to decreased attention. "I will plan to increase the amount of homework I assign to students who have ADHD." Faculty should decrease the amount of school work and homework given to a child who has ADHD to maintain their attention.
A nurse is teaching a group of parents about infectious mononucleosis. Which of the following statements by parent indicates an understanding the teaching?
"Mononucleosis is caused by an infection with the Epstein-Barr virus." The nurse should identify that mononucleosis is a mildly contagious illness that occurs sporadically or in groups, and is primarily caused by the Epstein-Barr virus. Wrong "Mononucleosis is a bacterial infection requiring 14 days of antibiotics." The nurse should identify that infectious mononucleosis is caused by the Epstein-Barr virus. No known specific treatment is available for mononucleosis. "A Monospot is a throat culture used to diagnosis mononucleosis." MY ANSWER The nurse should identify that a Monospot is a blood test that uses a special piece of paper to assist in diagnosing mononucleosis. "Children who get mononucleosis will need to refrain from sports for 6 months." The nurse should identify that a child who has mononucleosis should adjust their activities according to their level of fatigue. It is recommended that contact sports be avoided for about 4 weeks, or until splenomegaly has resolved.
A nurse is providing dietary teaching to the guardian of a school-age child who has cystic fibrosis. Which of the following statements should the nurse make?
"You should offer your child high-protein meals and snacks throughout the day." MY ANSWER The nurse should instruct the guardian to provide a diet that is well-balanced and high in protein and calories. Children who have cystic fibrosis require a higher percentage of the recommended dietary allowances of all nutrients to meet their energy requirements. Children who have good nutritional intake have improved lung function and decreased risk of infection. Wrong "You should decrease your child's dietary fat intake to less than 10% of their caloric intake." Children who have cystic fibrosis need a diet that is unrestricted in fat. They also require 35% to 40% of their calories to come from fats due to decreased absorption from the intestines. "You should restrict your child's calorie intake to 1,200 per day." Children who have cystic fibrosis require a high-calorie diet and should consume at least 2,000 calories per day. "You should give your child a multivitamin once weekly." Children who have cystic fibrosis should be given a multivitamin once daily.
A nurse in an emergency department is caring for a school-age child who has sustained a minor superficial burn from fireworks on their forearm. Which of the following actions should the nurse take?
Apply an antimicrobial ointment to the affected area. MY ANSWER The nurse should apply an antimicrobial ointment to the burned area to prevent infection. Wrong Administer the tetanus toxoid vaccine if more than 1 year since the prior dose. The nurse should administer the tetanus toxoid vaccine if it has been more than 5 years since the prior dose. Leave the burn area open to air. The nurse should apply a clean-dry dressing of fine mesh gauze and a light gauze dressing that restricts movement to prevent injury to the wound. Place an ice pack on the affected area. Applying ice to the affected area can impair circulation to the area and increase tissue damage.
A nurse is teaching the parents of a toddler who has cognitive impairment about toilet training. Which of the following instructions should the nurse include in the teaching?
Award your child with a sticker when they sit on the potty chair." MY ANSWER A child who has a cognitive impairment learns through shaping behaviors. The parents should reward the child for sitting on the potty chair as a reinforcement of the desired behavior of continence. As the child repeats this action, the parents can gradually decrease this reward and then give rewards for the next step in the task, such as voiding while sitting on the potty chair. Wrong "Scold your child when they have a toileting accident." The parents should use positive reinforcement when teaching their child a new task. Reinforcing positive behaviors, such as remaining dry through the night, will have a greater effect on the child than the negative reinforcement of scolding. "Play your child's favorite song while teaching them to use the potty chair." A child who has a cognitive impairment has difficulty discriminating between two or more cues or stimuli. The nurse should instruct the parents to eliminate all other stimuli when teaching the child the task of toilet training. "Teach multiple steps of the skill at the same time." Children who have a cognitive impairment have difficulty remembering multiple steps. The nurse should instruct the parents to teach one step at a time to the child. The child should master each step before the parents introduce the next step.
A school nurse is caring for a child following tonic-clonic seizure. Which of the following actions should the nurse take first?
Check the child's respiratory rate. MY ANSWER When using the airway, breathing, and circulation approach to client care, the nurse should determine the priority action is to assess the child's respiratory rate. If the child is not breathing, the nurse should administer rescue breaths. Wrong Observe for oral bleeding. During a tonic-clonic seizure, a child can lose muscle control and bite down on their tongue. It is important to check for oral bleeding following a tonic-clonic seizure; however, this is not the first action the nurse should take Check the child for a head injury. A tonic-clonic seizure is characterized by symmetric contraction and intense jerking movements of the child's body. If the child is standing or sitting in a chair, they will fall to the ground and a head injury can potentially occur. Therefore, it is important to check for a head injury following a tonic-clonic seizure; however, this is not the first action the nurse should take. Observe for extremity weakness. The client might experience extremity weakness due to intense jerking movements following a tonic-clonic seizure; however, this is not the first action the nurse should take.
A nurse in a providers office is caring for a school-age child who has varicella. The parents asks the nurse when their child will no longer be contagious. Which of the following responses should the nurse make?
Initiate airborne precautions for the child. MY ANSWER The nurse should initiate airborne precautions for a child who has varicella because it is spread through droplets in the air. The incubation period for varicella is 2 to 3 weeks, and the child is contagious even before lesions appear. Wrong Administer aspirin to the child for a temperature greater than 38.3° C (101° F). Guardians should be instructed to avoid the administration of aspirin when the child has a viral varicella infection due to the possibility of causing the development of Reye syndrome, which can be fatal. Prepare the child for a lumbar puncture. The nurse should prepare a child who has bacterial meningitis for a lumbar puncture. Maintain the child's room temperature at 80° F. The nurse should ensure that a child who has varicella remains cool. Cooler temperatures decrease pruritis. Maintaining the child's room at a warm temperature will increase the child's discomfort.
A nurse is an emergency department is caring for a school-age child who has epiglottitis. Which of the following actions should the nurse take?
Monitor the child's oxygen saturation. MY ANSWER The nurse should monitor the child's oxygen saturation level because the child is experiencing acute respiratory distress and it is necessary to determine if the child is responding to treatment. Wrong Obtain a throat culture from the child. Obtaining a throat culture places the child at risk for complete airway obstruction. The nurse should wait until an airway is established for the child before performing any diagnostic testing. Put a warm mist humidifier in the child's room. The nurse should administer humidified oxygen by face mask or blow-by, rather than place a warm mist humidifier in the child's room. Place the child in the supine position. Placing the child in the supine position increases the child's risk for complete airway obstruction. The nurse should allow the child to be in whatever position they feel provides the most help with breathing. This is usually an upright position, and sometimes it is helpful for the child to lean forward to help with breathing.
A nurse is caring for a 10-year-old child following a head injury. Which of the following findings should the nurse identify as an indication that the child is developing diabetes insipidus?
Sodium 155 mEq/L MY ANSWER A child who has a head injury can develop diabetes insipidus as a result of pituitary hypofunction leading to a deficiency of antidiuretic hormone. Underexcretion of antidiuretic hormone leads to polyuria and polydipsia, and possibly dehydration. With the excessive loss of free water, sodium levels rise above the expected reference range of 136 to 145 mEq/L. Wrong Urine specific gravity 1.045 Urine specific gravity of 1.045 is above the expected reference range of 1.005 to 1.030. A child who has diabetes insipidus is more likely to have diluted urine and a urine specific gravity below the expected reference range. Blood glucose 45 mg/dL Blood glucose of 45 mg/dL is below the expected reference range of 70 to 110 mg/dL. A child who has diabetes insipidus is expected to have a blood glucose level within the expected reference range. Urine output 35 mL/hr Urinary output of 35 mL/hr is within the expected reference range of 33 to 58 mL/hr for a 10-year-old child. A child who has diabetes insipidus is expected to have polyuria.
A nurse is providing discharge teaching to the parents of a 6-month-old infant who is postoperative following hypospadias repair with a stent placement. Which of the following instructions should the nurse include in the teaching?
"Allow the stent to drain directly into your infant's diaper." The nurse should instruct the parents to ensure that the stent drains directly into the infant's diaper to prevent kinking or twisting that can interfere with urine flow. Wrong "You should clamp your infant's stent twice daily." The stent in place following hypospadias repair allows urine to drain from the body. The nurse should instruct the parents to avoid blocking the stent to prevent urinary stasis and potential injury to the infant. Apply hydrocortisone cream to your infant's penis daily." MY ANSWER Following surgical repair of a hypospadias, the infant is at increased risk for infection at the operative site. The nurse should instruct the parents to administer a prophylactic antibiotic as prescribed to help prevent infection. Apply hydrocortisone cream to your infant's penis daily." MY ANSWER Following surgical repair of a hypospadias, the infant is at increased risk for infection at the operative site. The nurse should instruct the parents to administer a prophylactic antibiotic as prescribed to help prevent infection.
A nurse is planning n educational program to teach parents about protecting their children from sunburns. Which of the following instructions should the nurse plan to include?
"Choose a waterproof sunscreen with a minimum SPF of 15." The nurse should instruct parents to apply a waterproof sunscreen with a minimum SPF of 15 for children. The parents should apply the sunscreen prior to sun exposure to reduce the risk of sunburn. Wrong "Allow your child to play outside during the hours between 10:00 a.m. and 2:00 p.m." The nurse should instruct parents to avoid allowing their children to play outside during the hours between 1000 and 1400 because the child is at greatest risk for developing a sunburn during this time. "Dress your child in loose weave polyester fabric prior to sun exposure." The nurse should instruct parents to dress their children in tight weave cotton fabric prior to sun exposure to protect the skin from the sun. "Reapply sunscreen every 4 hours." MY ANSWER The nurse should instruct parents to reapply sunscreen every 2 to 3 hr.
A nurse is providing teaching to the parents of a preschooler who has heart failure and a new prescription for digoxin twice daily. Which of the following instructions should the nurse include in the teaching?
"Brush the child's teeth after giving the medication." MY ANSWER The nurse should instruct the parents to brush the child's teeth after administering digoxin to prevent tooth decay caused by the medication, which comes as a sweetened liquid to enhance the taste. Wrong "Use a kitchen teaspoon to measure the medication." The nurse should instruct the parents to use the calibrated device that comes with the medication when measuring the medication to avoid accidental overdose. "Double the next dose if the child misses a dose." The parent should administer digoxin at regular intervals, usually twice daily, or every 12 hr. The nurse should instruct the parents not to double the medication amount if they miss a dose because this can result in digoxin toxicity. "Repeat the dose if the child vomits." Nausea, vomiting, and decreased appetite are common manifestations of digoxin toxicity in children. The nurse should instruct the parents not to administer a second dose if the child vomits and to notify the provider.
A nurse is providing teaching to the family of a school-age child who has juvenile idiopathic arthritis. Which if the following instructions should the nurse include in the teaching?
"Encourage the child to perform independent self-care." MY ANSWER The nurse should teach the family the importance of encouraging the child to perform independent self-care. This will minimize the child's pain while maximizing mobility. Encouraging and praising the child's efforts for independence will also increase their self-esteem. Wrong "Limit movement of the child's large joints." Large joints should be exercised regularly to maintain mobility and strengthen muscles. "Provide the child with a soft mattress for sleeping." Children who have juvenile idiopathic arthritis should sleep on a firm mattress to provide support in maintaining joints in a functional position. "Schedule a 2-hour daily nap for the child in the afternoon." Daytime naps are discouraged because stiffness can occur quickly and easily with inactivity, and naps can interfere with nighttime sleeping.
A nurse is providing discharge teaching to the parent of an 18-month-old toddler who has dehydration due to acute diarrhea. Which of the following statements by the parent indicates an understanding of the teaching?
"I will monitor my child's number of wet diapers." MY ANSWER The nurse should teach the parent to closely monitor the child's number of wet diapers. Monitoring the number of wet diapers per day is an effective way for the parent to monitor adequate output and hydration status. Wrong "I will avoid giving my child solid foods until the diarrhea has stopped." The nurse should teach the parent to encourage solid foods as soon as the toddler is rehydrated to provide adequate nutrient intake. "I will offer my child small amounts of fruit juice frequently." Children recovering from dehydration should not be encouraged to drink frequent, small amounts of fruit juice because it is high in carbohydrates, low in electrolytes, and has a high osmolality value. "I will give my child polyethylene glycol daily for 7 days." Polyethylene glycol is an osmotic agent that will pull fluid into the bowel, increasing the frequency of stools, which will increase the level of dehydration.
A nurse is providing discharge teaching to the guardian of a school-age child who has undergone a tonsillectomy. Which of the following statements by the guardian indicates an understanding the teaching?
"I will notify the doctor if I notice that my child is swallowing frequently." MY ANSWER The nurse should instruct the parent that frequent swallowing is an indication of bleeding and, if it is observed, to notify the provider immediately. Wrong "My child will be able to drink the chocolate milkshake I promised to get for them tonight." Milk products should be avoided because they coat the child's throat, which can initiate a cough response and increase the risk of bleeding. Brown and red foods should be avoided during the immediate postoperative period so that food and fresh or old blood are distinguishable in the child's emesis. "My child can resume usual activities since this was just an outpatient surgery." Activity should be limited following a tonsillectomy to decrease the risk of hemorrhage. "I will have my child gargle with warm salt water to relieve their sore throat." Gargles are likely to cause irritation and discomfort and can increase the risk of bleeding following a tonsillectomy. The child should receive adequate pain medication following the procedure and can wear an ice collar if tolerated.
A nurse is providing discharge teaching to the parent of a school-age child who has moderate persistant asthma. Which of the following instructions should the nurse include?
"Pulmonary function tests will be performed every 12 to 24 months to evaluate how your child is responding to therapy." The nurse should inform the parent that their child will need pulmonary function tests every 12 to 24 months to evaluate the presence of lung disease and how the child is responding to the current treatment regimen. As children grow, sometimes their manifestations can improve or decline, and treatment needs to change accordingly. Wrong You should give your child their salmeterol inhaler every 4 hours when they are having an acute episode of wheezing." The nurse should inform the parent that long-acting beta2 agonists are to be used in conjunction with a low- or medium-dosage inhaled corticosteroid, and never used alone. Using this medication alone on an as-needed basis during an acute asthma attack is dangerous and can lead to worsening of the child's condition. "You should monitor your child's weight weekly while they are receiving inhaled corticosteroid therapy." The nurse should instruct the parent that the use of inhaled corticosteroids has not been shown to have any negative effects on growth. The provider might monitor the child's growth for systemic absorption; however, it is not necessary for the parent to weigh the child weekly. "Pulmonary function tests will be performed every 12 to 24 months to evaluate how your child is responding to therapy." The nurse should inform the parent that their child will need pulmonary function tests every 12 to 24 months to evaluate the presence of lung disease and how the child is responding to the current treatment regimen. As children grow, sometimes their manifestations can improve or decline, and treatment needs to change accordingly. "When using the peak expiratory flow meter, record your child's average of three readings." MY ANSWER The nurse shoul
A nurse is receiving change-of-shift report for four children. Which of the following children should the nurse assess first?
A toddler who has a concussion and an episode of forceful vomiting MY ANSWER When using the urgent vs. nonurgent approach to client care, the nurse should assess this child first. An episode of forceful vomiting is an indication of increased intracranial pressure in a toddler who has a concussion. Wrong An adolescent who has infective endocarditis and reports having a headache A report of a headache is nonurgent because it is an expected finding for a child who has infective endocarditis. Therefore, the nurse should assess another child first. An adolescent who was placed into halo traction 1 hr ago and reports pain as 6 on a scale of 0 to 10 A report of moderate pain is nonurgent because it is an expected finding for a child who has a new halo traction device. Therefore, the nurse should assess another child first. A school-age child who has acute glomerulonephritis and brown-colored urine Brown-colored urine is nonurgent because it is an expected finding for a school-age child who has acute glomerulonephritis. Therefore, the nurse should assess another child first.
A nurse assessing a school-age child who has an infratentorial brain tumor. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure?
Difficulty concentrating MY ANSWER The nurse should identify that irritability, inability to follow commands, and difficulty concentrating are manifestations of increased intracranial pressure due to decreased blood flow within the brain and pressure on the brainstem. Wrong Hypotension The nurse should identify that hypertension is a late manifestation of increased intracranial pressure due to compression of the brain vessels. Reports insomnia The nurse should identify that somnolence and lethargy are manifestations of increased intracranial pressure. Tachycardia The nurse should identify that bradycardia is a late manifestation of increased intracranial pressure.
A charge nurse is preparing to make a room assignment for a newly admitted school-age child. Which of the following considerations is the nurses priority?
Disease process The transmission of infectious diseases is the greatest risk to this child and other children on the unit. Therefore, the child's disease process is the nurse's priority consideration. Wrong Length of stay It is important for the nurse to consider the child's anticipated length of stay because some client rooms might be larger, and thus more comfortable for families during long hospitalizations. However, this is not the nurse's priority consideration. Treatment schedule MY ANSWER It is important for the nurse to consider the child's treatment schedule when making room assignments because children requiring frequent monitoring and treatment should be assigned a room close to the nurses' station, if possible. However, this is not the nurse's priority consideration. Self-care ability It is important for the nurse to consider the child's self-care ability when making room assignments because children who require more assistance from nurses or assistive personnel should be assigned a room close to the nurses' station, if possible. However, this is not the nurse's priority consideration.
A nurse is caring for a toddler who has acute otitis media and a temperature of 40 C (104 F). After administering acetaminophen, which of the following actions should the nurse plan to take to reduce the toddler's temperature?
Dress the toddler in minimal clothing. MY ANSWER The nurse should recognize that dressing the toddler in minimal clothing will expose the skin to air and maximize heat evaporation from the skin, thus reducing the toddler's temperature. Wrong Apply a cooling blanket to the toddler. Applying a cooling blanket can cause shivering and discomfort, which increases metabolic requirements. The nurse should be aware that the use of a cooling blanket is indicated for the treatment of hyperthermia, but not a fever. Give the toddler a tepid bath. A tepid bath is lukewarm, which can cause discomfort to the toddler. The nurse should be aware that the use of a tepid bath is indicated for the treatment of hyperthermia, but not a fever. Administer diphenhydramine to the toddler. Diphenhydramine is an antihistamine indicated for the treatment of an allergic reaction. The nurse should identify that antipyretics, such as acetaminophen, are indicated for the treatment of a fever.
A nurse is planning care for a newly admitted schole-age child who has generalized seizure disorder. Which of the following interventions should the nurse plan to include?
Ensure the oxygen source is functioning in the child's room. MY ANSWER The nurse should recognize that maintaining the child's airway is important during a seizure. The nurse should ensure that the oxygen source is functioning because the child might require supplemental oxygen following a seizure. Wrong Allow the child to take a tub bath independently. The nurse should allow the child to take a tub bath with supervision, but not independently. There should be someone available to assist the child if they experience a seizure. Allow the child to play video games on a tablet computer. Bright or flashing lights from video games can trigger seizure activity. The nurse should decrease environmental stimuli and offer other play activities, such as reading a book or playing with a stuffed animal. Ensure that a padded tongue blade is at the child's bedside. Nothing should be placed in the child's mouth during or after a seizure. Therefore, placing a padded tongue blade at the child's bedside is not an action the nurse should take.
A nurse is admitting a 4-month-old infant who has heart failure. Which of the following findings is the nurse's priority? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data
Episodes of vomiting MY ANSWER When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is three episodes of vomiting. This can indicate digoxin toxicity, which requires immediate intervention. Therefore, this is the nurse's priority finding. Wrong Formula consumption A 4-month-old infant who has heart failure requires 3 to 4 oz of formula every 3 hr to adequately address caloric needs. A feeding schedule of every 2 hr does not allow sufficient rest time between feedings, and a feeding schedule of every 4 hr requires consumption of a higher volume, which is often not tolerated by the infant. An intake of 3 to 4 oz of formula every 3 hr indicates that the infant is tolerating the current feeding schedule. Therefore, there is another finding that is the nurse's priority. The infant who has heart failure is at risk for inadequate nutrition; therefore, the nurse should closely monitor the infant's intake. Wrong Weight A weight of 5.9 kg (13 lb) is an expected finding for a 4-month-old infant who weighed 3.2 kg (7 lb) at birth. Therefore, there is another finding that is the nurse's priority. The infant should gain 680 g (1.5 lb) per month until the age of 5 months. Temperature A temperature of 37.5º C (99.5º C) is within the expected reference range of 37º to 37.5º C (98.6º to 99.5º F) for a 4-month-old infant. Therefore, there is another finding that is the nurse's priority.
A nurse is reviewing the laboratory results of a school-age child who is 1 week postoperative following an open fracture repair. Which of the following findings should the nurse identify as an indication of a potential complication?
Erythrocyte sedimentation rate 18 mm/hr The nurse should identify that an erythrocyte sedimentation rate of 18 mm/hr is above the expected reference range of up to 10 mm/hr and is an indication of osteomyelitis. Wrong WBC count 6,200/mm3 The nurse should identify that a WBC count of 6,200/mm3 is within the expected reference range of 5,000 to 10,000/mm3. An elevated WBC count is an indication of ost C-reactive protein 1.4 mg/L The nurse should identify that a C-reactive protein level of 1.4 mg/L is within the expected reference range of less than 10.0 mg/L. An elevated C-reactive protein level is an indication of osteomyelitis. RBC count 4.7 million/mm3 MY ANSWER The nurse should identify that an RBC count of 4.7 million/mm3 is within the expected reference range of 4.0 to 5.5 million/mm3. A decreased RBC count can indicate hemorrhage.
A nurse is providing anticipatory guidance to the parent of a toddler. Which of the following expected behavior characteristics of toddlers should the nurse include?
Expresses likes and dislikes MY ANSWER The nurse should include that expressing likes and dislikes is an expected behavior of toddlers. This is the time in life when a toddler is developing autonomy and self-concept. They will try to assert themselves and frequently refuse to comply. The parent should allow the child to have some control, but also set limits for them so they learn from their behavior and learn to control their actions. Wrong Easily separates from parents for long periods of time A toddler might be able to separate from their parents for a short period of time, but the toddler is more likely to experience acute separation anxiety when separated from their parents for an extended period of time. The toddler might offer resistance if they are left with a new babysitter or at a new day care center. Understands right from wrong Understanding right from wrong and modifying their behavior in response to others' expectations is an expected behavior of preschoolers. Toddlers tend to have a great deal of curiosity and ask many questions but are not able to fully understand what behaviors are right or wrong. Controls impulsive feelings Controlling impulsive feelings is an expected behavior of school-age children. A toddler is more likely to have difficulty controlling strong and impulsive feelings as they try to assert their independence and gain control of situations.
A nurse is assessing the pain level of a 3-year-old toddler. Which of the following pain assessment scales should the nurse use?
FACES MY ANSWER The nurse should use the FACES pain rating scale for pediatric clients who are 3 years old and older. This scale allows the toddler to point to the face that depicts their current level of pain. The nurse can then determine the need for pain management. Wrong Numeric The nurse should use the numeric pain rating scale when assessing the need for pain management in pediatric clients who are 8 years old and older. The nurse should identify that a 3-year-old toddler does not yet possess a concept of numbers and numerical value to effectively use this pain rating scale. CRIES The nurse should use the CRIES pain assessment scale when assessing the need for pain management in infants who are less than 40 weeks of age. Visual analogThe nurse should use the visual analog scale to assess pain for a child who is greater than 8 years of age. The visual analog scale allows the child to mark their pain on a centimeter ruler.
A nurse is creating a plan of care for a newly admitted adolescent who has bacterial meningitis. How long should the nurse plan to maintain the adolescent in droplet precautions?
For 24 hr following initiation of antimicrobial therapy The nurse should plan to maintain the adolescent on droplet precautions for at least 24 hr following initiation of antimicrobial therapy. This practice will ensure that the adolescent is no longer contagious, which protects family members and the personnel caring for the client. Prophylactic antibiotics might be prescribed to individuals who were in close contact with the adolescent. Wrong Until the adolescent has a negative blood culture MY ANSWER Blood cultures should be drawn before the first dose of antibiotics. It usually takes 48 to 72 hr for the organism to grow enough for identification. The test should be repeated after the entire antibiotic regimen is completed to determine if the infection is still present. Therefore, blood cultures are not a determinant factor for removing a client from droplet precautions. For 7 days following admission to the facility The adolescent is not contagious for 7 days. Therefore, it is not necessary for the nurse to maintain droplet precautions for that length of time. Until the adolescent is afebrile A temperature within the expected reference range for an adolescent can be achieved with acetaminophen. Therefore, this is not a determinant factor for removing a client from droplet precautions.
A nurse is planning care to address nutritional needs for a preschooler who has cystic fibrosis. Which of the following interventions should the nurse include in the plan?
Increase fat content in the child's diet to 40% of total calories. A child who has cystic fibrosis is unable to properly digest fats due to fibrosis of the pancreas and limited secretion of pancreatic enzymes. The nurse should increase the child's fat intake to 35% to 40% of total caloric intake. Wrong Limit fluid intake to 750 mL per day. The nurse should encourage fluid intake, rather than restrict it, to prevent dehydration caused by the loss of sodium and chloride through perspiration. Discontinue the use of pancreatic enzymes if steatorrhea develops. A child who has cystic fibrosis and develops steatorrhea, or fatty stools, might need to have their dosage of pancreatic enzyme increased by their provider until the steatorrhea resolves. Administer pancreatic enzymes 2 hr after meals. MY ANSWER The nurse should plan to administer pancreatic enzymes within 30 min of meals and snacks to replace the enzymes lost with cystic fibrosis.
A nurse in an emergency department is assessing a toddler who has Kawasaki disease. Which of the following findings should the nurse expect? (Select all that apply.)
Increased temperature is correct. Kawasaki disease is an acute illness associated with a fever that is unresponsive to antipyretics or antibiotics. Xerophthalmia is correct. Ophthalmic manifestations of Kawasaki disease include reddening of the conjunctiva and dryness of the eyes, or xerophthalmia. Cervical lymphadenopathy is correct. A child who has Kawasaki disease can develop enlarged cervical nodes on one side of the neck that are nontender and greater than 1.5 cm in size. Wrong Gingival hyperplasia is incorrect. Children who have Kawasaki disease develop a strawberry tongue, cracked lips, and edema of the oral mucosa and pharynx. A child who is receiving phenytoin therapy can develop gingival hyperplasia. Bradycardia is incorrect. Kawasaki disease is an infection that affects the vascular system, including the heart. The nurse should expect the child to be tachycardic with a gallop rhythm. Long-term effects of Kawasaki disease include the development of coronary artery aneurysms or myocardial infarction.
A nurse is assessing an 8-year-old child who has early indications of shock. After establishing an airway and stabilizing the childs respirations, which of the following actions should the nurse take next?
Initiate IV access. MY ANSWER After establishing an airway and stabilizing the child's respirations, the next action the nurse should take when using the airway, breathing, and circulation approach to client care is to establish IV access to maintain the child's circulatory volume. Wrong Maintain ECG monitoring. The nurse should maintain ECG monitoring for a child who has early indications of shock to continually assess for changes in cardiac status. However, there is another action that the nurse should take first. Measure weight and height. The nurse should measure weight and height of a child who has early indications of shock to calculate weight-based medication dosages. However, there is another action that the nurse should take first. Insert an indwelling urinary catheter. The nurse should insert an indwelling urinary catheter for a child who has early indications of shock. Strict intake and output monitoring is needed because urinary output decreases during shock due to reduced blood flow to the kidneys as the body attempts to conserve body fluids. However, there is another action that the nurse should take first.
A nurse is assessing an infant who has pneumonia. Which of the following findings is the priority for the nurse to report to the provider?
Nasal flaring MY ANSWER 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 nasal flaring. Nasal flaring indicates the infant is experiencing acute respiratory distress. Wrong WBC count 11,300/mm3 The nurse should report a WBC count of 11,300/mm3 because it is above the expected reference range of 5,000 to 10,000/mm3 and indicates infection. However, there is another finding that is the priority for the nurse to report. Diarrhea The nurse should report diarrhea because it is a manifestation of pneumonia in infants and indicates the current treatment is not effective. However, there is another finding that is the priority for the nurse to report. Abdominal distension The nurse should report abdominal distension because it is a manifestation of pneumonia in infants and indicates the current treatment is not effective. However, there is another finding that is the priority for the nurse to report.
A nurse is caring for a school-age child who has peripheral edema. The nurse should identify that which of the following assessments should be performed to confirm peripheral edema?
Palpate the dorsum of the child's feet. The nurse should palpate the dorsum of the feet by pressing the fingertip against a bony prominence for 5 seconds to assess for peripheral edema. Wrong Weigh the child daily using the same scale. MY ANSWER Weighing the child daily might indicate that the child has retained fluid. However, this is not a method the nurse should use to assess for peripheral edema. Assess the child's skin turgor. Assessing the child's skin turgor measures the elasticity and mobility of the skin. However, this is not a method the nurse should use to assess for peripheral edema. Observe the child for periorbital swelling. Observing the child for periorbital swelling is a method used to assess for generalized edema. However, this is not a method the nurse should use to assess for peripheral edema.
A nurse is caring for an infant who is receiving IV fluids for the treatment of Tetralogy of Fallot and begins to have hypercryanotic spell. Which of the following actions should the nurse take?
Place the infant in a knee-chest position. MY ANSWER The nurse should place the infant in a knee-chest position during a hypercyanotic spell to decrease the return of desaturated venous blood from the legs and to direct more blood into the pulmonary artery by increasing systemic vascular resistance. Wrong Administer a dose of meperidine IV. The nurse should administer morphine IV to the infant, instead of meperidine, to decrease infundibular spasms that cause a decrease in pulmonary blood flow and right-to-left shunting. Discontinue administration of IV fluids. The nurse should continue the administration of IV fluids during a hypercyanotic spell to decrease the viscosity of the infant's blood, which decreases the risk of a cerebrovascular accident. Apply oxygen at 2 L/min via nasal cannula. The nurse should apply oxygen at 100% via face mask to assist with dilation of the pulmonary artery and improve oxygen supply to the brain.
A nurse is caring for a preschooler who has congestive heart failure. The nurse observes wide QRS complexes and peaked T waves on the cardiac monitor. Which of the following prescriptions should the nurse clarify with the provider?
Potassium chloride MY ANSWER The nurse should identify that a child who has congestive heart failure can develop electrolyte imbalances, such as hyperkalemia or hypokalemia. The nurse should identify that the child is exhibiting manifestations of hyperkalemia and contact the provider about the administration of potassium chloride, which can increase the severity of hyperkalemia. Wrong Regular insulin A child who has congestive heart failure can develop electrolyte imbalances, such as hyperkalemia or hypokalemia. The nurse should identify that the child is exhibiting manifestations of hyperkalemia and that insulin should be administered to facilitate the movement of potassium into the cells. Captopril A child who has congestive heart failure will require medications that cause vasodilation, such as ACE inhibitors, to reduce cardiac afterload. FurosemideA child who has congestive heart failure might need a diuretic to prevent fluid overload from heart failure. Furosemide is a loop diuretic that excretes potassium. Since the child is exhibiting manifestations of hyperkalemia, this medication is safe to administer.
A nurse is planning developmental activities for a newly admitted 10-year-old child who has neutropenia. Which of the following actions should the nurse plan to take?
Provide the child with a book about adventure. MY ANSWER The nurse should provide a school-age child with a book about adventure as a developmental activity because children are expanding their knowledge and imagination during this age. Through reading, school-age children can feel powerful and skillful as they imagine themselves in the stories they read. Wrong Arrange frequent visits from family members and peers. The nurse should limit visitors for a child who has neutropenia because this places the child at an increased risk for infection. Give the child a large-piece puzzle. The nurse should provide a large-piece puzzle to a preschooler. School-age children tend to be challenged mentally with complex board and video games. Use puppets to entertain the child. The nurse should use puppets to entertain toddlers. School-age children are not typically entertained for very long or challenged mentally with puppets. Instead, they tend to prefer complex board and video games.
A nurse is caring for a newly admitted school-age child who has hypopituitarism. Which of the following medications should the nurse expect the provider to prescribe?
Recombinant growth hormone Recombinant growth hormone injections are used to treat hypopituitarism, which inhibits cell growth and results in growth failure. The nurse should expect the provider to prescribe this treatment. Wrong Levothyroxine Levothyroxine is used to treat various hypothyroid conditions. Levothyroxine Levothyroxine is used to treat various hypothyroid conditions. Desmopressin MY ANSWER Desmopressin is used to treat hyposecretion of antidiuretic hormones.
A nurse is providing discharge teaching to the guardians of a toddler who had lower leg cast applied 24 hr ago. The nurse should instruct the guardians to report which of the following finding to the provider?
Restricted ability to move the toes MY ANSWER The nurse should inform the guardians that a restricted ability of the toddler to move their toes is an indication of neurovascular compromise and requires immediate notification of the provider. Permanent muscle and tissue damage can occur in just a few hours. Wrong Capillary refill time less than 2 seconds Capillary refill time is assessed to determine circulatory status by pressing lightly on the tips of the toes until the skin has blanched. A capillary refill time that is greater than 2 seconds indicates circulatory compromise and should be reported to the provider immediately. Swelling of the casted foot when the leg is dependent Swelling of the casted foot when the leg is dependent is an expected finding. The nurse should instruct the guardians that frequent rest is needed for the next several days, and that the casted foot should not be in a dependent position for more than 30 min. When the toddler is resting, the casted extremity should be elevated on a pillow at chest level to minimize swelling. Pedal pulse +3 bilateral A pulse that is not easily obliterated with pressure is graded as a +3 and is an expected finding that indicates adequate circulation of the extremity. An absent pulse indicates circulatory compromise and should be reported to the provider immediately.
A nurse in an emergency department is assessing a 3-month-old infant who has rotavirus and is experiencing acute vomiting and diarrhea. Which of the following manifestations should the nurse identify as an indication that the infant has moderate to severe dehydration?
Sunken anterior fontanel The nurse should recognize that a sunken anterior fontanel is an indication of moderate to severe dehydration due to the acute loss of fluid. Wrong Heart rate 124/min MY ANSWER A heart rate of 124/min is within the expected reference range of 106 to 186/min for a 3- to 5-month-old infant. The nurse should expect the infant who has moderate to severe dehydration to have tachycardia. Increased tear production An infant who has moderate to severe dehydration is more likely to have absence of tears rather than increased tear production. Capillary refill 2 seconds A capillary refill of 2 seconds is within the expected reference range of 2 seconds or less for a 3-month-old infant. An infant who has moderate to severe dehydration is more likely to have delayed capillary refill of greater than 2 seconds.
A nurse is planning an educational program for school-age children and their parents about bicycle safety. Which of the following information should the nurse plan to include?
The child should be able to stand on the balls of their feet when sitting on the bike. MY ANSWER To decrease the risk for injury, parents should ensure that the bike is the correct size for the child. When seated on the bike, the child should be able to stand with the ball of each foot touching the ground and should be able to stand with each foot flat on the ground when straddling the bike's center bar. Wrong The child should ride their bike 2 feet to the side of other bike riders. To decrease the risk for injury, children should ride their bikes single file rather than side by side. The child should wear dark-colored clothing with a fluorescent stripe when riding at night. To decrease the risk for injury when riding a bike at night, children should wear light-colored clothing that has fluorescent material attached. This measure, along with fluorescent material on the bike itself, makes bike riders more visible to motor vehicle drivers and other bike riders. The child should ride the bike facing traffic when it is necessary to ride in the street. To decrease the risk for injury, bike riders should ride in the direction of the flow of traffic.
A nurse is planning care for a school-age child who has tunneled central venous access device. Which of the following interventions should the nurse include in the plan?
Use a semipermeable transparent dressing to cover the site. MY ANSWER The nurse should cover the site with a semipermeable transparent dressing to reduce the risk of infection. Wrong Access the site using a noncoring angled needle. The nurse should use a noncoring angled or straight needle when accessing an implanted port. Irrigate each lumen weekly with 10 mL of 0.9% sodium chloride solution when not in use. The nurse should flush each lumen of the catheter with a heparin solution daily when not in use. Use sterile scissors to remove the dressing from the site. The nurse should avoid the use of scissors when performing dressing changes because this can result in accidental cutting of the catheter.
A nurse is admitting an infant who has intussusception. Which of the following findings should the nurse expect? (Select all that apply.)
Vomiting is correct. The nurse should expect an infant who has intussusception to exhibit vomiting due to the obstruction that occurs when a segment of the bowel telescopes within another segment of the bowel. Lethargy is correct. The nurse should expect an infant who has intussusception to exhibit lethargy due to episodes of severe pain during which the infant cries inconsolably, leading to exhaustion and decreased nutritional intake. Wrong Steatorrhea is incorrect. The nurse should expect an infant who has intussusception to have bloody stools that are currant jelly-like in appearance. Steatorrhea is bulky, fatty stools, and is a manifestation of cystic fibrosis. Constipation is incorrect. The nurse should expect an infant who has intussusception to have mucus-filled and red jelly-like diarrhea due to the leaking of blood and mucus into the intestinal lumen. Weight gain is incorrect. The nurse should expect an infant who has intussusception to have weight loss due to anorexia and episodes of vomiting and diarrhea.
A nurse is providing discharge teaching to the parents of a Caucasian toddler who had a lower leg cast applied 24 hr ago. The nurse should instruct the parents to report which of the following findings to the provider Restricted ability to move the toe A nurse in an emergency department is auscultating the lungs of an adolescent who is experiencing dyspnea. The nurse should identify the sound as which of the following? (Click on the audio button to listen to the clip
Wheezes MY ANSWER The nurse should identify the sound during auscultation as wheezes, which are high-pitched, musical or whistling-like sounds heard primarily on expiration as air passes through and vibrates narrowed airways. Wrong Crackles The nurse should identify crackles as high-pitched, short, and noncontinuous sounds usually heard at the end of inspiration. Crackles occur when air expands deflated alveoli or when the passage of air through small airways is disrupted. Pleural friction rub The nurse should identify a pleural friction rub as a loud, rough, grating sound that can be heard during inspiration or expiration. A pleural friction rub occurs when the pleurae are inflamed and the surfaces rub together. Rhonchi The nurse should identify rhonchi as low-pitched, continuous sounds that have a snore-like quality and are usually louder during expiration. Rhonchi occur when the larger airways are obstructed.