ATI: Nursing Care of Children (ALL: Book, adaptive quizzes, assessments A & B)

A nurse is reinforcing teaching about otic medication administration with the guardian of an 18 month old toddler. Which of the following statements should the nurse make? A. "Administer the drops immediately after removing the medication from the refrigerator." B. "Place the child in a seated position with the head tilted to the side for administration." C. "Gently pull the ear cartilage down and back when administering the medication." D. "Position the medication bottle so the drops do not touch the side of the ear canal."

"Gently pull the ear cartilage down and back when administering the medication."

A nurse is reinforcing teaching about expected changes during puberty to a group of guardians of early adolescent girls. Which of the following statements by one of the guardians indicates an understanding of the information? A. "Girls usually stop growing about 2 years after menarche." B. "Girls are expected to gain about 65 pounds during puberty." C. "Girls experience menstruation prior to breast development." D. "Girls typically grow more than 10 inches during puberty."

"Girls usually stop growing about 2 years after menarche."

A nurse is reinforcing teaching with the caregiver of an infant who has a prescription for digoxin. Which of the following statements should the nurse make? A. "Do not offer your baby fluids after giving the medication." B. "Digoxin increased your baby's heart rate." C. "Give the correct dose of medication at regularly scheduled times." D. "If your baby vomits a dose, you should repeat the dose to ensure that the correct amount is received."

"Give the correct dose of medication at regularly scheduled times."

A nurse in a community center is reinforcing teaching with a group of adolescents about HIV/AIDS. Which of the following statements should the nurse include in the teaching? A. "You can contract HIV through casual kissing." B. "HIV is transmitted through IV substance use." C. "HIV is now curable if caught in the early stages." D. "Medications inhibit inhibit transmission of the HIV virus."

"HIV is transmitted through IV substance use."

A nurse is a provider's office is collecting data from the caregiver of a school-aged child who requires intermittent catheterization. Which of the following questions should the nurse ask the caregiver when monitoring the child for a urinary tract infection (UTI)? A. "How long ago was the child's last catherization?" B. "Have you noticed a change in the color of the child's urine during catheterization?" C. "Do you use sterile technique when inserting the child's catheter?" D. How far do you insert the catheter before urine begins to flow?"

"Have you noticed a change in the color of the child's urine during catheterization?"

A school nurse is providing home care instructions to the guardian of a school-aged child who has acute streptococcal pharyngitis. Which of the following statements should the nurse make? A. "Replace your child's toothbrush after administering the first dose of the antibiotic." B. "Your child should stay home from school until taking antibiotics for 48 hours." C. "Ensure your child eats small meals every 3 hours." D. "Have your child gargle with warm saline several times each day."

"Have your child gargle with warm saline several times each day."

A nurse is reinforcing teaching with the guardian of a preschooler. The guardian reports the preschooler has has an imaginary playmate for about 3 months. Which of the following pieces of information should the nurse reinforce with the guardian? A. "Children commonly begin having imaginary friends when they reach school age." B. "Notify your provider if the imaginary friend persists longer than 6 months." C. "Have your child take responsibility for actions if they try to blame the imaginary friend." D. "Set limits by not allowing the child to have the imaginary friend present during family meals."

"Have your child take responsibility for actions if they try to blame the imaginary friend."

A nurse is caring for a 16 year old client who reports dysmenorrhea and asks about alternative therapies for treatment. Which of the following statements should the nurse make? A. "Herbal medication can be effective but should be monitored by your provider." B. "You should place a cold compress on your lower abdomen to decrease inflammation." C. "You should limit exercise, which can increase the pain." D. "Avoid touching the painful areas because this can increase your discomfort."

"Herbal medication can be effective but should be monitored by your provider."

A nurse is reinforcing teaching with the family of a child about hospice care. Which of the following statements should the nurse include in the teaching? A. "The hospice staff will be the primary caregivers for the child." B. "Hospice staff members consider the family's needs to be just as important as those of the child." C. "Hospice care will end with the death of your child." D. "The priority of hospice care is to provide curative treatment for the child."

"Hospice staff members consider the family's needs to be just as important as those of the child."

A nurse is monitoring a child who is receiving a transfusion of packed RBCs. Which of the following responses by the child is an indication of a transfusion reaction? A. "My nose is runny. Can I have a tissue?" B. "I am hungry. Can I get a snack?" C. "I am sleepy. I might take a nap after this." D. "I am cold. Can I have an extra blanket."

"I am cold. Can I have an extra blanket."

A nurse is preparing to administer a vaccine to a 4 year old child. Which of the following statements should the nurse include in the preparation for this procedure? A. "Your father is going to be outside the room while I give you the shot." B. "I am going to give you some medication that will go under your skin." C. "This medication doesn't hurt that much." D. "This will feel like a bee sting."

"I am going to give you some medication that will go under your skin."

A nurse is evaluating teaching that was provided for an adolescent who has a new prescription for a brace for scoliosis. Which of the following statements indicates an understanding of the teaching? A. "I can only remove the brace for 1 hour each day." B. "I cannot wear anything under the brace." C. "I will have to stop participating in any physical sports during my treatment." D. "I can loosen the straps of the brace if I notice any reddened areas."

"I can only remove the brace for 1 hour each day."

A nurse is reinforcing teaching with a school-aged child who has a new diagnosis of acute lymphoblastic leukemia (ALL). Which of the following statements from the child indicates an understanding of the teaching? A. "Once treatment starts, I won't feel so tired." B. "This started because of that terrible illness I had last month. C. "My parents will do things for me so I don't get tired." D. "I have a good chance of surviving this cancer."

"I have a good chance of surviving this cancer."

A nurse is discussing firearm safety with the parent of an adolescent. Which of the following statements should the nurse identify as an indication that the parent understands the basic principles of firearm safety? A. "I will consider allowing my child to take a gun safety course in the next few years." B. "My child knows I strictly forbid anyone handling my gun." C. "I would know if my child was interested in using my gun." D. "I keep my gun in a locked safe and my child does not have access to my key."

"I keep my gun in a locked safe and my child does not have access to my key."

A nurse is reinforcing teaching with a parent of an infant who has a colostomy. Which of the following statements indicates an understanding of the teaching? A. "I will not use 1-piece outfits for my child." B. "I need to buy diapers that are tighter than my infant usually wear." C. "I need to apply paste to the back of the wafer on my child's appliance." D. "I will not need to toilet-train my child."

"I need to apply paste to the back of the wafer on my child's appliance."

A nurse is reinforcing teaching with the parent of an infant who has a new diagnosis of human immunodeficiency virus (HIV). Which of the following statements made by the parent indicates an understanding of the teaching A. "The antiretroviral medication will stop the progression of the disease." B. "It won't be possible for my child to attend daycare." C. "I should bring my child in for immunizations on schedule." D. "My child's nutritional needs will not change."

"I should bring my child in for immunizations on schedule."

A nurse is reinforcing teaching with the guardian of an infant who has tetralogy of Fallot. Which of the following guardian responses indicates an understanding of the teaching? A. "I should bring the baby's knees toward her chest for cyanotic episodes." B. "I will expect my baby's cyanotic episodes to occur most often during the evening." C. "I should limit my baby's total fluid intake to decrease the frequency of cyanotic episodes." D. "I will give my baby oxygen through a nasal cannula during cyanotic episodes."

"I should bring the baby's knees toward her chest for cyanotic episodes."

A nurse is reinforcing teaching about dental care and teething to the caregiver of a 9 month old infant. Which of the following statements by the caregiver suggests an understanding of the teaching? A. "I can give my baby a warm teething ring to relieve discomfort." B. "I should clean my baby's teeth with a cool, wet wash cloth." C. "I can give Advil for up to 5 days while my baby is teething." D. "I should place diluted juice in the bottle my baby drinks while falling asleep."

"I should clean my baby's teeth with a cool, wet wash cloth."

A nurse is reinforcing teaching with the parent of a 4 year old child who has a tracheostomy. Which of the following parent statements indicates an understanding of the teaching? A. "I will need to use sterile gloves when I perform the suctioning." B. "I should cover the tracheostomy tube with a thin cloth whenever we go outside." C. I should clean the stoma with 50% strength hydrogen peroxide every 6 hours." D. "I should be able to slip 2 fingers underneath the tracheostomy ties."

"I should cover the tracheostomy tube with a thin cloth whenever we go outside."

A nurse is reinforcing teaching with a child who has type 1 diabetes mellitus about self-care. Which of the following statements by the child indicates understanding of the teaching? A. "I should skip breakfast when I am not hungry." B. "I should increase my insulin with exercise." C. "I should drink a glass of milk when I am feeling irritable." D. "I should draw up the NPH insulin into the syringe before the regular insulin."

"I should drink a glass of milk when I am feeling irritable."

A nurse is reinforcing care instructions with the parent of a child who has a newly placed gastrostomy tube. Which of the following statements demonstrates an understanding of the instructions" A. "I should maintain a steady pull on the G tube during feedings." B. "I should flush the tube with water in between administering each medicine." C. "I should aspirate before each feeding to be certain the tube is in the correct place." D. "I should use half-strength hydrogen peroxide to clean the site until the skin has healed."

"I should flush the tube with water in between administering each medicine."

A nurse is reinforcing teaching about interventions for mild hypoglycemia with the parent of a child who has diabetes mellitus. Which of the following statements by the parent indicates that the teaching has been effective? A. "I should administer a glucagon injection to my child." B. "I should give my child 5 grams of a simple carbohydrate." C. "I should give my child 4 ounces of orange juice followed by cheese and crackers." D. "I should give my child a snack that is 10 percent of his daily caloric intake."

"I should give my child 4 ounces of orange juice followed by cheese and crackers."

A nurse is reinforcing teaching with the parent of a child who has ADHD and new prescription for methylphenidate sustained-release tablets. Which of the following statements by the parent indicates an understanding of the teaching? A. "I should expect my child to gain weight while taking this medication." B. "I should expect this medication to decrease my child's heart rate." C. "I should crush the medication and put it in my child's food." D. "I should give this medication to my child half an hour before breakfast."

"I should give this medication to my child half an hour before breakfast."

A nurse is reinforcing teaching with the parent of a newborn who has plagiocephaly. Which of the following statements by the parent indicates an understanding of the instructions? a. "I should put my baby to sleep on the belly during her afternoon nap." b. "I should ensure my baby's head is in the same position whenever sleeping." c. "I should have my baby wear the prescribed helmet 23 hours a day." d. "I should allow my baby to sleep in an infant swing."

"I should have my baby wear the prescribed helmet 23 hours a day."

The nurse is reinforcing teaching for the parent of a 4 year old child who stutters. Which of the following statements by the parent indicates an understanding of the teaching? A. "I should ignore the stuttering and not interrupt her." B. "I should finish my child's sentence if she is stuck on a word." C. "I should reward my child when she doesn't stutter." D. "I should tell my child to slow down when she starts stuttering."

"I should ignore the stuttering and not interrupt her."

A nurse is reinforcing teaching about home safety and poisoning with the guardian of a toddler. Which of the following statements by the guardian indicates understanding? A. "I will punish my toddler for playing with my medications." B. "I should immediately call the poison control center if my toddler takes any of my medication." C. "I will put my medications in the top drawer in my bathroom." D. "I should keep my bag zipped closed if I have any medication inside of it."

"I should immediately call the poison control center if my toddler takes any of my medication."

A nurse is reinforcing discharge teaching with the parent of a newborn who has been prescribed a Pavlik harness for developmental dysplasia of the hip. Which of the following responses indicates an understanding of the teaching? A. "I should apply powder to the folds of skin on my baby's knees and thighs." B. "I should adjust the straps on the harness once a week as my baby grows." C. "I should lightly massage my baby underneath the straps once a day." D. "I should place my baby's diaper over the straps of the harness."

"I should lightly massage my baby underneath the straps once a day."

A nurse is reinforcing teaching about injury prevention with the parent of an infant. Which of the following statements by the parent indicates an understanding of the teaching? A. "I should lightly shake talcum powder on my baby's skin after each diaper change." B. "I should use a drop-side crib after my baby is 6 months old." C. "I should make sure my baby's clothing does not have buttons on it." D. "I should ensure the crib slats are no more than 3 inches apart."

"I should make sure my baby's clothing does not have buttons on it."

A nurse is reinforcing teaching with the guardian of an infant who has Down syndrome. Which of the following statements by the guardian indicates an understanding of the teaching? A. "I should expect him to have frequent diarrhea." B. "I should place a cool mist humidifier in his room." C. "I should avoid the use of lotion on his skin." D. "I should expect him to grow faster in length than other infants."

"I should place a cool mist humidifier in his room."

A nurse is reinforcing teaching with the parents of a 4-month-old infant who has gastroesophageal reflux. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will place my baby on her side when sleeping." B. "I will add 1 teaspoon of rice cereal per ounce to my baby's formula." C. "I will decrease the number of feedings my baby receives per day." D. "I will give my baby loperamide with each feeding."

"I will add 1 teaspoon of rice cereal per ounce to my baby's formula."

A nurse is reinforcing teaching with the parents of a 10 year old child who has iron-deficiency anemia. Which of the following statements by a parent indicates an understanding of the teaching? A. "I will give my child an iron tablet once each day at bedtime." B. "I will administer the iron tablet with orange juice." C. "I will encourage my child to take an antacid with the iron tablet." D. "I will crush the iron tablet prior to giving it to my child."

"I will administer the iron tablet with orange juice."

A nurse is reinforcing teaching about sudden infant death syndrome (SIDS) with the parent of a 1 month old infant. Which of the following statements by the parents indicates an understanding of the teaching? A. "I will let my baby sleep with me in bed at night." B. "I will allow my baby to have a pacifier while sleeping." C. "I will place my baby on a soft mattress to sleep." D. "I will cover my baby with a quilt while he is sleeping."

"I will allow my baby to have a pacifier while sleeping."

A nurse is reinforcing teaching with the parent of an infant who has developmental hip dysplasia and a new prescription for a Pavlik harness. Which of the parent statements of the teaching? A. "I will apply the harness over a t-shirt and knee socks." B. "I will be certain to put on my baby's diaper over the harness." C. "I will make the required harness adjustments as my baby grows." D. "I will apply powder around the harness buckles each day."

"I will apply the harness over a t-shirt and knee socks."

A nurse is a pediatric clinic is reinforcing teaching with the parent of a school-aged child who has type 1 diabetes mellitus and an upper respiratory infection. Which of the following statements by the parent indicates an understanding of the instructions? A. "I will give my child half of the usual insulin dose until the infection is clear." B. "I will monitor my child's urine for ketones once a day." C. "I will notify the provider if my child's random glucose level is greater than 140." D. "I will check my child's blood glucose level every 3 hours."

"I will check my child's blood glucose level every 3 hours."

A nurse is reinforcing teaching about disease management with the parent of a preschooler who has a new diagnosis of asthma. Which of the following parent statements indicates an understanding of the teaching? A. "My child should not receive live virus vaccines." B. "I will encourage my child to participate in sports." C. "I will give my child aspirin when she has a fever." D. "My child will outgrow asthma by adulthood."

"I will encourage my child to participate in sports."

A nurse is reinforcing postoperative teaching with the parent of a 3 month old infant who is recovering from an umbilical hernia repair. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will expect to see bulging at the site when my baby is crying." B. "I will place a belly band around my child's abdomen." C. "I will fold my baby's diaper away from the incision." D. "I will bathe my child in the bathtub daily."

"I will fold my baby's diaper away from the incision."

A nurse is reinforcing teaching about liquid oral supplements with the guardian of a school-age child who has iron deficiency anemia. Which of the following statements by the guardian indicates an understanding of the teaching? A. "I will give my child a double dose of this medication if she misses a dose." B. "I will give this medication to my child with a cup of skim milk." C. "This medication will turn my child's stools white." D. "I will give this medication to my child with a straw."

"I will give this medication to my child with a straw."

A nurse is reinforcing discharge teaching with the guardian of a child who has juvenile idiopathic arthritis (JIA). Which of the following statements by the guardian indicates an understanding of the teaching? A. "I will have my child sleep in knee, wrist, and hand splints." B. "I will encourage my child to take an afternoon nap." C. "I will apply topical hydrocortisone to my child's joints as needed." D. "I will administer opioids to my child for the next several months to control the pain."

"I will have my child sleep in knee, wrist, and hand splints."

A nurse is reinforcing teaching to the guardian of a preschooler about methods to promote sleep. Which of the following statements by the guardian indicates an understanding of the teaching? A. "I will sleep in the bed with my child if she wakes up during the night." B. "I will let my child stay up an additional 2 hours on weekend nights." C. "I will let my child watch television for 3 minutes just before bedtime each night." D. "I will keep a dim light on in my child's room during the night."

"I will keep a dim light on in my child's room during the night."

A nurse is caring for a child who has a terminal illness and reviews palliative care with an assistive personnel (AP). Which of the following statements by the AP indicates understanding of this review? A. "I'm sure the family is hopeful that the new medication will stop the illness." B. "I'll miss working with this client now that only nurses will be caring for the child." C. "I will get all the client's personal objects out of the room." D. "I will listen and respond as the family talks about their child's life."

"I will listen and respond as the family talks about their child's life."

A nurse is reinforcing discharge teaching with the guardian of a school-age child who has a new prescription for home oxygen therapy. Which of the following statements by the guardian indicates an understanding of the teaching? A. "I will restrict the length of the oxygen tubing to no longer than 3 feet." B. "I will place the extra oxygen tanks in a horizontal position for storage." C. "I will check the oxygen delivery equipment once every week." D. "I will make sure that electrical devices in the house are grounded."

"I will make sure that electrical devices in the house are grounded."

A nurse is present at the time of a child's death following a terminal illness. Which of the following statements should the nurse make to the child's parent? A. "If you'll excuse me, I'll go call the funeral home to have them pick up your child." B. "Your child is no longer suffering." C. "I will miss your child's infectious laugh; it always made me smile." D. "You should consider how to share the news of your child's death with her siblings."

"I will miss your child's infectious laugh; it always made me smile."

A nurse is reinforcing teaching about home care with the guardian of a 14 month old toddler who has spastic cerebral palsy. Which of the following statements by the guardian indicates an understanding of the teaching? A. "I will perform daily stretching exercises to my toddler's affected muscles." B. "I will ensure my toddler avoids activities that involve repetitive joint movements." C. "I will place my toddler on his stomach to nap after meals." D. "I will give my toddler pain medication just after he performs strenuous activities."

"I will perform daily stretching exercises to my toddler's affected muscles."

A nurse is reinforcing teaching about home safety with the parent of a toddler. Which of the following parent statements indicates an understanding of the teaching? A. "I will keep my hearing aid batteries in my bedside table." B. "I will place a screen in front of the fireplace." C. "I will keep my medication in my purse." D. "I will use a steam vaporizer when my child has a cold."

"I will place a screen in front of the fireplace."

A nurse is reinforcing teaching about home care with the guardian of a school-aged child who has seizures. Which of the following statements by the guardian indicates an understanding of the teaching? A. "I will call an abulance if my child's seizure lasts more than 10 minutes." B. "I will offer my child clear liquids immediately following a seizure." C. "I will tightly hold my child to restrain him during a seizure." D. "I will turn my child onto his side when a seizure begins."

"I will turn my child onto his side when a seizure begins."

A nurse is reinforcing teaching with the parent of a preschooler who has impetigo. Which of the following statements by the parent indicates an understanding of the teaching? A. "Impetigo is caused by a virus." B. "Impetigo is contagious for 48 hours after vesicles rupture." C. "I will wash my child's clothes in hot water." D. "My child now has immunity against impetigo."

"I will wash my child's clothes in hot water."

A nurse is caring for a toddler who has terminal cancer and is receiving hospice care. The child's parent tells the nurse, "I'm a bad parent, and I can't deal with this." Which of the following responses should the nurse make? A. "I'm not sure I follow you. Can you explain?" B. "I understand. Other parents say the same thing." C. "Let's talk about home care for your child." D. "I disagree. You're a great parent."

"I'm not sure I follow you. Can you explain?"

A nurse is reinforcing teaching with a 12 year old child who is recovering from an acute bleeding episode of hemophilia A. Which of the following statements should the nurse make? A. "Be sure to stay in bed for 72 hours after the bleeding has stopped." B. "You should take ibuprofen before during a bleeding episode to relieve warm, swollen, and painful joints." C. "If you have a bleeding injury, you should immediately apply pressure and ice to the site." D. "You can safely resume contact sports 4 days after bleeding has stopped."

"If you have a bleeding injury, you should immediately apply pressure and ice to the site."

A parent of a school-age child who has GH deficiency asks the nurse how long the child will need to take injections for growth delay. Which of the following responses should the nurse make? A. "Injections are usually continued until age 10 for girls and age 12 for boys." B. "Injections continue until your child reaches the fifth percentile on the growth chart." C. "Injections might be stopped once your child grows less than 1 inch/year." D. "The injections will need to be administered throughout your child's entire life."

"Injections might be stopped once your child grows less than 1 inch/year."

A nurse is reinforcing teaching with a 14 year old client who has acne. Which of the following instruction should the nurse include? A. "Use an exfoliating cleanser." B. "Keep hair off your forehead." C. "Take tetracycline after meals." D. "Squeeze acne lesions as they appear."

"Keep hair off your forehead."

A nurse is reinforcing discharge teaching with the guardian of a school-age child who has acute lymphocytic leukemia and an absolute neutrophil count of 450/mm3. Which of the following instructions should the nurse include? A. "Allow your child to receive the varicella immunization." B. "Take your child's rectal temperature twice per day." C. "Increase your child's intake of fresh fruits and vegetables." D. "Keep your child away from crowded areas."

"Keep your child away from crowded areas."

A nurse on a pediatric unit is caring for a child who is not eating well. Which of the following suggestions should the nurse reinforce with the child's food intake? A. "Make dietary choices for your child." B. "Offer foods that have strong flavors or smells." C. "Let the child eat with others when possible." D. "Make sure the child eats the majority of food on his plate."

"Let the child eat with others when possible."

A nurse is caring for an adolescent client who is practicing Jehovah's Witness and is scheduled for surgery for a ruptured appendix. The adolescent tells the nurse that based on their religious beliefs, they cannot receive a blood transfusion. Which of the following responses should the nurse make? A. "Why do members of your faith believe this?" B. "You'll only receive blood during the procedure if you need it." C. "I will let the surgical team know your wishes." D. "Let's discuss the possible need for a transfusion with your parents."

"Let's discuss the possible need for a transfusion with your parents."

A nurse in a pediatric is talking on the telephone with the parent of a 6 month who has a urinary tract infection and started taking an oral antibiotic the day before. Listen to the audio clip and determine which of the following responses the nurse should make. A. "Mix the medicine with 1/4 cup of juice before giving it to your baby." B. "Mix the medicine with 1 teaspoon of honey before giving it to your baby." C. "Mix the medicine with 1/4 cup of formula before giving it to your baby." D. "Mix the medicine with 1 teaspoon of applesauce before giving it to your baby."

"Mix the medicine with 1 teaspoon of applesauce before giving it to your baby."

A nurse in a pediatric clinic is caring for an infant who has hear failure and a prescription for digoxin. Which of the following statements by the parent indicates the desired therapeutic effect of the medication? A. "My baby is breathing easier than she use to." B. "My baby is taking longer naps." C. "My baby is having fewer wet diapers." D. "My baby's heart rate is faster than it used to be."

"My baby is breathing easier than she use to."

A nurse is talking with the parent of a 4 month old infant about growth and development. Which of the following statements indicates that the parent needs further instructions? A. "I need to remind my older kids to keep small objects out of the baby's reach." B. "I let my baby play on her stomach when she is awake and I am watching. C. "My baby loves to play with the pillows in her crib." D. "I put my baby in a rear-facing car seat in the back seat of the car."

"My baby loves to play with the pillows in her crib."

A nurse is reinforcing teaching regarding the immunization schedule with the parent of a 6 month old infant during a well baby visit. Which of the following statements by the parent indicates an understanding of the teaching? A. "My baby will receive his third DTaP vaccine today." B. "My baby is old enough to receive the varicella vaccine today." C. "My baby will receive his final polio vaccine today." D. "My baby will receive his first hepatitis B vaccine today."

"My baby will receive his third DTaP vaccine today."

A nurse in a provider's office is caring for a preschooler who has findings of croup. Which of the following statements by the parent requires immediate intervention by the nurse? A. "My child has refused to drink any fluid for the past hours." B. "My child has been coughing throughout the night." C. "My child is very hoarse and has a fever by 100.4 degrees Fahrenheit." D. "My child recently had the flu."

"My child has refused to drink any fluid for the past hours."

A nurse is reinforcing teaching with the guardian of a child who has a new diagnosis of rheumatic fever. Which of the following statements by the guardian indicates an understanding of the teaching? A. "I should not give my child aspiring for pain or fever." B. "My child will take antibiotics for 6 months." C. "My child might have a period of irregular movement of the extremities." D. "I should expect there to be blood in my child's urine."

"My child might have a period of irregular movement of the extremities."

A nurse is reinforcing teaching about growth and development characteristics to the guardian on a 2 year old toddler. Which of the following statements by the guardian indicates an understanding of the teaching? A. "My child should be able to turn the pages of a book one a time." B. "My child should be able to walk on their tiptoes for several steps." C. "My child should be able to cut out an outline using scissors." D. "My child should be able to put the toys away after using them."

"My child should be able to turn the pages of a book one a time."

A nurse is reinforcing teaching to the guardians of a child who is to have an electroencephalogram (EEG). Which of the following statements by a guardian indicates teaching was effective? A. "My child should remain quiet and still during this procedure." B. "I cannot wash my child's hair prior to the procedure." C. "I should not give my child anything to eat prior to the procedure." D. "This procedure will be very painful for my child."

"My child should remain quiet and still during this procedure."

A nurse is reinforcing teaching to the parent of a child who has a new prescription for liquid oral iron supplements. Which of the following statements by the parent indicates an understanding? A. "I should take my child to the emergency department if his stools become dark." B. "My child should avoid eating citrus fruits while taking the supplements." C. "I should give the iron with milk to help prevent an upset stomach." D. "My child should take the supplement through a straw."

"My child should take the supplement through a straw."

A nurse is reinforcing teaching with a group of parents of adolescents about developmental needs. Which of the following statements by a parent should the nurse investigate further? A. "My child has frequent mood swings." B. "My child has a very messy bedroom." C. "My child takes 1 to 2 showers per day." D. "My child spends 4 hr per day in internet chat rooms."

"My child spends 4 hr per day in internet chat rooms."

A nurse is caring for a school-age girl who is being treated for a frequent, severe urinary tract infections (UTIs). The nurse should recognize that which of the following statements by the parent indicates a possible cause of the UTIs? A. "My daughter has bowel movements every 4 to 5 days." B. "I taught her to wipe from front to back after going to the bathroom." C. "She urinates every 2 to 3 hours during the day." D. "I don't let her wear nylon underwar."

"My daughter has bowel movements every 4 to 5 days."

A nurse is reinforcing teaching with the guardian of a toddler who has fifth disease. Which of the following statements should the nurse include in the teaching? A. "Once a red rash appears on your child's cheeks, he is no longer contagious to others." B. "When all the vesicles have crusted, your child is no longer contagious to others." C. "Your child will be contagious to others until 5 days after the rash appears." D. "After 24 hours of antibiotic therapy, your child will no longer be contagious to others."

"Once a red rash appears on your child's cheeks, he is no longer contagious to others."

A nurse is reinforcing teachings with a group of guardians about influenza. Which of the following information should the nurse include? A. "Amantadine will prevent the illness." B. "The influenza vaccine is recommended for children 4 months and older." C. Zanamivir can be given to children 1 year and older." D. "Oseltamivir should be given within 48 hours of onset of manifestations."

"Oseltamivir should be given within 48 hours of onset of manifestations."

A nurse is reinforcing teaching about preventing poisoning with a group of parents who have toddlers. Which of the following statements should the nurse make? A. "Keep medications on a counter that is out of reach of the toddler." B. "Do not allow live plants in the house." C. "Put all cleaning supplies in a locked cabinet." D. "Allow your child to eat from his or her favorite ceramic bowls."

"Put all cleaning supplies in a locked cabinet."

A nurse is collecting data for a developmental assessment on a 3 year old client. Which of the following commands should the nurse expect the child to successfully complete? A. "Put on your shoes." B. "Name the days of the week." C. "Cut out this picture with a pair of scissors." D. "Balance on a foot with your eyes closed."

"Put on your shoes."

A nurse is reinforcing teaching about glucose monitoring with the parent of a child who has type 1 diabetes mellitus. Which of the following instructions should the nurse include in the teaching? A. "Press the platform of the lancet firmly against your child's finger." B. "Obtain the blood sample from the center of your child's finger pad." C. "Put your child's finger under warm, running water prior to collecting blood." D. "Steady the finger against a hard surface while puncturing the skin."

"Put your child's finger under warm, running water prior to collecting blood."

A guardian calls the clinic nurse after his child has developed symptoms of varicella and asks when the child will no longer be contagious. Which of the following responses should the nurse make? A. "When your child no longer has a fever." B. "Three days after the rash started." C. "Six days after lesions appear if they are crusted." D. "When your child's lesions disappear."

"Six days after lesions appear if they are crusted."

A nurse is reinforcing teaching with the family of a child who has autism spectrum disorder. Which of the following statements indicates that he family understands the instructions? A. "Donepezil might slow the progression of the disorder." B. "My child will prefer group therapy with other children." C. "Structuring our daily routine will help our child." D. "Our child probably has this condition as a result of prematurity."

"Structuring our daily routine will help our child."

A nurse on a pediatric mental health unit is caring for a school-aged child. Which of the following questions or statements should the nurse make to foster rapport and engage him in conversation? A. "Do you like school?" B. "Tell me about your favorite video game." C. "We have another child who's your age on the unit." D. "Would you like your friends to visit you?"

"Tell me about your favorite video game."

A nurse is caring for a toddler who has a hip dysplasia and has been placed in a hip spica cast. The child's guardian asks the nurse why a PPavlik harness is not being used. Which of the following responses should the nurse make? A. "The Pavlik harness is used for children with scoliosis, not hip dysplasia." B. "The Pavlik harness is used for school-age children." C. "The Pavlik harness cannot be used for your child because their condition is too severe." D. "The Pavlik harness is used for infants less than 6 months of age."

"The Pavlik harness is used for infants less than 6 months of age."

A nurse is reinforcing teaching with a guardian about parallel play in children. Which of the following statements should the nurse include? A. "Children sit and observe other playing." B. "Children exhibit organized play when in a group." C. "The child plays alone." D. "The child plays independently when in a group."

"The child plays independently when in a group."

A nurse is reviewing the medical record of a 2 month old infant who has rotavirus. The nurse notes a hemoglobin level of 12 g/dL and a hematocrit of 51%. Which of the following statements made by the nurse indicates an understanding of these laboratory values A. "The infant might be dehydrated." B. "The infant might become anemic." C. "The infant might have received too much fluid." D. "The infant might have leukemia."

"The infant might be dehydrated."

A nurse is reinforcing teaching with the parent of a toddler who is undergoing the insertion of tympanostomy tubes. Which of the following statements should the nurse include? A. "The doctor will replace the tubes routinely about every 2 hours." B. "Getting water in her ears will not cause any further problems." C. "The tubes should stay in place until they fall out on their own." D. "Now that the tubes are in place, she should not have any further problems with hearing."

"The tubes should stay in place until they fall out on their own."

A nurse is reinforcing teaching with an adolescent client who has scoliosis. When discussing how to wear the back brace, the client appears to be holding back tears. Which of the following responses should the nurse make? A. "This is a lot of new information to absorb about back braces; can you tell me your thoughts on what we have discussed?" B. "The back brace is only temporary; the next 6 months of wearing it will be over before you know it." C. "Others will not notice the back brace if you wear loose clothing." D. "Are you concerned about wearing the back brace?"

"This is a lot of new information to absorb about back braces; can you tell me your thoughts on what we have discussed?"

A nurse is reinforcing teaching about oxycodone with an adolescent who is experiencing a vaso-occlusive crisis. Which of the following pieces of information should the nurse include? A. "This medication can cause diarrhea." B. "This medication can cause an increase in blood pressure." C. "This medication might cause nausea." D. "This medication can cause an increase in salvation."

"This medication might cause nausea."

A nurse is reinforcing teaching with a group of parents of toddlers about growth and development. A parent asks, "Why does my child's abdomen stick out?" Which of the following statements should the nurse provide A. "You should give your child a stool softener daily. B. "Toddlers gain weight at a rapid pace." C. "You should have your child assessed for a spinal deformity." D. "Toddlers do not have well-developed abdominal muscles."

"Toddlers do not have well-developed abdominal muscles."

A nurse is talking with a parent of a preschooler. The parent reports that her child becomes upset at night and does not go to bed at a consistent time. Which of the following instructions should the nurse give the parent? A. "Use a stable, relaxing routine such as a bath and story time before bed." B. "Make sure the room is completely dark when placing your child in bed." C. "Let your child go to sleep in your lap and then put him in his bed." D. "Respond consistently if your child cries out for you after putting him to bed."

"Use a stable, relaxing routine such as a bath and story time before bed."

A nurse is reinforcing teaching with the guardian of a 9-month-old infant who has a new prescription for an oral liquid medication. Which of the following points should the nurse include in the teaching? A. "Mix the medication into a small amount of your infant's formula to disguise the taste." B. "Use an oral syringe to measure your infant's medicine accurately." C. "Position your infant supine when administering the medication." D. "Assist your infant with drinking the medicine from a small paper cup."

"Use an oral syringe to measure your infant's medicine accurately."

A nurse is reinforcing teaching about prevention with the parents of a 3 year old child who has persistent otitis media. Which of the following statements by the parents indicates an understanding of the teaching? A. "My child should not play around others who have ear infections." B. "We should not smoke around our child." C. "My child should not swim this summer." D. "I will encourage my child to blow her nose forcefully when she has a cold."

"We should not smoke around our child."

A nurse is reinforcing home safety instructions with the parents of a toddler. Which of the following parent statements indicates an understanding of the teaching? A. "We will keep our child out of the sun between 3 p.m. and 5 p.m." B. "We will transition our child to a toddler bed when he is 2 feet tall." C. "We will purchase a toy storage box with a lightweight lid." D. "We will provide a healthy snack of peanuts."

"We will purchase a toy storage box with a lightweight lid."

A nurse is teaching the parent of a child who has ADHD and a new prescription for methylphenidate sustained-release tablets. Which of the following pieces of information should the nurse include in the teaching? A. "Crush the medication and mix it in your child's food." B. "Administer the medication 1 hour before bedtime." C. "Expect your child to have cloudy urine while he is taking this medication." D. "Weigh your child twice per week while he is taking this medication."

"Weigh your child twice per week while he is taking this medication."

A nurse is reinforcing teaching with the guardian of a toddler about preventing burn injuries. Which of the following pieces of information should the nurse include? A. "When using an air vaporizer in the home, ensure it is a cool-mist vaporizer." B. "You should set your water heater thermostat to 135 F" C. "When cooking on a stove, be sure to turn pot handles toward the side of the stove." D. "You can allow your child to blow out matches while you are present."

"When using an air vaporizer in the home, ensure it is a cool-mist vaporizer."

A nurse on a pediatric oncology unit is helping the parents of a child who is terminally ill to prepare for the impeding loss of their child. Which of the following statements should the nurse make? A. "The nursing staff will bathe your child and take care of his daily needs." B. "Your child will be most comfortable in a low-stimulation environment." C. "Would you like assistance in planning where your child will die?" D. "Would you like hospice to continue providing curative care in your home?"

"Would you like assistance in planning where your child will die?"

A nurse is reinforcing teaching with the parent of an infant who has a newly created colostomy. Which of the following instructions should the nurse reinforce about colostomy care? A. "Using an ostomy appliance with a ring is typically the best choice for an infant." B. "You can choose to use a diaper instead of a collection bag." C. "The collection bag should be replaced each day." D. "You will need to irrigate the ostomy bag every other day."

"You can choose to use a diaper instead of a collection bag."

A nurse is reinforcing teaching with a school-aged child who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements should the nurse make? A. "If you take too much insulin, drink a sugar-free cola." B. "You will need to decrease your insulin dosage when you become a teenager." C. "You can use a vial of insulin for up to 30 days." D. "Stop taking your insulin if you are vomiting."

"You can use a vial of insulin for up to 30 days."

A nurse is reinforcing teaching with the guardian of an infant who has seborrheic dermatitis of the scalp. Which of the following instructions should the nurse include? A. "You can use petrolatum to help soften and remove patches from your infant's scalp." B. "When patches are present, you should keep your infant away from others." C. "You should avoid washing your infant's hair while patches are present on the scalp." D. "When patches are present, it indicates that your infant has a systemic infection."

"You can use petrolatum to help soften and remove patches from your infant's scalp."

A nurse is reinforcing teaching with an adolescent client who has type 1 diabetes mellitus about managing hypoglycemia. Which of the following statements should the nurse include in the teaching? A. "You should drink 8 oz of a regular soft drink if you experience hypoglycemia." B. "You should drink 4 oz of orange juice if you experience hypoglycemia." C. "You should take 2 glucose tablets if you experience hypoglycemia." D. "You should take 3 tsp of sugar if you experience hypoglycemia."

"You should drink 4 oz of orange juice if you experience hypoglycemia."

A nurse is reinforcing teaching with a school-age child who has diabetes mellitus about insulin administration. Which of the following instructions should the nurse include? A. "You should inject the needle at a 30 degree angle." B. "You should combine our glargine and regular insulin in the same syringe." C. "You should aspirate for blood before injecting the insulin." D. "You should give four to six injections in one area before switching sites."

"You should give four to six injections in one area before switching sites."

A nurse is reinforcing teaching on strategies to decrease allergen exposure with a parent whose child has asthma. Which of the following statements should the nurse include? A. "You should ensure your child cleans and vacuums his room every week." B. "You should use a wood burner for heat in the winter as much as possible." C. "You should not allow your child to have any stuffed toys in bed." D. "You should watch closely for any signs of roaches in your home."

"You should watch closely for any signs of roaches in your home."

A nurse is reinforcing teaching with a 12 year old client who is recovering from an acute episode of hemophilia A. Which of the following statements should the nurse include in the teaching? A. "Have your parent stretch and move your legs for you." B. "Apply heat to joints that become painful, stiff, and swollen." C. "Take aspirin at the first sign of a headache." D. "You will be able to participate in physical exercises."

"You will be able to participate in physical exercises."

A nurse is reinforcing teaching with an adolescent female client who has acne vulgaris and a new prescription for isotretinoin. Which of the following information should the nurse include? A. "You should apply this medication to the affected skin twice daily." B. "You will need to have two negative pregnancy tests prior to starting this medication." C. "Your provider will monitor your kidney function while you are taking this medication." D. "Your provider will prescribe a vitamin A supplement to take with each dose of this medication."

"You will need to have two negative pregnancy tests prior to starting this medication."

A nurse is reinforcing teaching with the parents of a toddler who had an anaphylactic reaction to peanut butter about administering injectable epinephrine. Which of the following instructions should the nurse include? A. "Common sites for an injection of epinephrine are the fatty tissue found in the upper arm and in the lower abdomen." B. "Administer epinephrine prior to giving your child peanut products in the future." C. "No future treatment is needed after injecting the epinephrine." D. "You will need to increase the dosage as your child gains weight."

"You will need to increase the dosage as your child gains weight."

A nurse is reinforcing preoperative teaching with an adolescent client who is scheduled to receive spinal instrumentation for scoliosis. Which of the following information should the nurse include? A. "You will go home the same day of surgery." B. "You will have minimal pain." C. "You will need to receive blood." D. "You will not be able to eat until the day after surgery."

"You will need to receive blood."

A nurse is caring for a toddler who has had rhinitis, cough, and diarrhea for 2 days. The tympanic membrane has an orange discoloration and decreased movement. Which of the following statements should the nurse make? A. "Your child has an ear infection that requires antibiotics." B. "Your child could experience transient hearing loss." C. "Your child will need to be on a decongestant until this clears." D. "Your child will need to have to have a myringotomy."

"Your child could experience transient hearing loss."

A nurse is reinforcing teaching with the parents of a child who has cerebral palsy. Which of the following statements should the nurse make? A. "Your child will be unable to eat by mouth." B. "Your child will be unable to participate in recreational activities." C. "Your child will need a botulinum toxin A injection to help with muscle spasticity." D. "Your child will need throw rugs placed over non-carpeted areas."

"Your child will need a botulinum toxin A injection to help with muscle spasticity."

A nurse is reinforcing teaching about disease management strategies with a 9 year old client who has cystic fibrosis. Which of the following statements should the nurse include? A. "Thorough and effective pulmonary clearance can reduce your chance of needing a lung transplant when you get older." B. "You should eat these kinds of foods because they will help you grow big and strong." C. "Your mucus is thick because cystic fibrosis interferes with how your glands work." D. "Your medication will be given on a schedule to help you sleep better."

"Your mucus is thick because cystic fibrosis interferes with how your glands work."

A nurse is preparing to administer digoxin 0.015 mg/kg/day PO divided equally every 12 hours to an infant who weighs 20 lb. Digoxin oral solution 0.1 mg/1 mL is available. How many mL should the nurse administer per dose? (round to the nearest tenth)

0.7 mL

A charge nurse is reviewing the expected growth and development of school-aged children with a group of staff nurses. Which of the following statements should the nurse include? A. "A 7 year old child prefers to play with children of a different gender." B. "A 6 year old child should understand the concept of cause and effect." C. "A 6 year old child should be able to count 13 coins." D. "An 8 year old child should be able to wash his or her own hair independently."

"A 6 year old child should be able to count 13 coins."

A nurse is reinforcing discharge teaching with the parent of a school-age child who is being treated for nephrotic syndrome. The parents asks the nurse why it is necessary to check the child's urine for protein. Which of the following explanations should the nurse offer? A. "A decrease in urine protein indicates that treatment is effective." B. "Protein in the urine indicates your child's protein intake is adequate." C. "Protein in the urine indicates a need to begin dialysis." D. "An increase in urine protein indicates your child has a secondary infection."

"A decrease in urine protein indicates that treatment is effective."

A nurse in an acute care unit is caring for an adolescent who has exacerbation of cystic fibrosis. The adolescent has 5 younger siblings at home and reports to the nurse that his parents have not brought the siblings to visit. Which of the following responses should the nurse make? A. "You should ask your parents to bring them to visit individually." B. "Why do you think they haven't brought your siblings in to visit?" C. "Are you concerned because your parents haven't brought your siblings to visit you?" D. "I know it is hard, but you can see them all when you go home in a few days."

"Are you concerned because your parents haven't brought your siblings to visit you?"

A nurse is reinforcing teaching with the family of a preschooler whose parent has a terminal diagnosis. Which of the following statements should the nurse include when discussing age-appropriate responses to death? A. "Your child will likely exhibit fear of the impending death with verbal uncooperativeness." B. "At this age, your child will understand that death is irreversible." C. "Your child will likely be curious about what happens to the body after death." D. "At this age, your child likely believes his thoughts can cause another person's death."

"At this age, your child likely believes his thoughts can cause another person's death."

A nurse is teaching an adolescent client who has juvenile rheumatoid arthritis. Which of the following instructions should the nurse include in the teaching? A. "Apply cold compresses to relieve joint pain." B. "Take opioids routinely." C. "Attend school regularly." D. "Adhere to an arthritis diet."

"Attend school regularly."

A nurse is reinforcing teaching with a guardian about complicated grief. Which of the following statements should the nurse make? A. "Complicated grief occurs when little time is spent thinking about the loss." B. "Personal activities are rarely affected when experiencing complicated grief." C. "Guardians will experience complicated grief together." D. "Counseling can be helpful in resolving complicated grief."

"Counseling can be helpful in resolving complicated grief."

A nurse is collecting data from a preschooler who has recurrent and persistent otitis media. When obtaining the child's history from her parent, which of the following questions should the nurse ask? A. "Does your child wear a hat outdoors in cold weather? B. "Does anyone smoke around or in the same house as your child?" C. "Have you given your child any aspirin recently?" D. "Is your child's diet high in gluten?"

"Does anyone smoke around or in the same house as your child?"

A nurse is reinforcing teaching with a group of caregivers about fractures. Which of the following information should the nurse include? A. "Children need longer time to heal from a fracture than an adult." B. "Epiphyseal plate injuries can result in altered bone growth." C. "A greenstick fracture is a complete break in the bone." D. "Bones are unable to bend, so they break."

"Epiphyseal plate injuries can result in altered bone growth."

A nurse is reinforcing teaching with the parent of an 8 year old child who has AIDS. Which of the following instructions should the nurse highlight? A. "You should plan low-calorie, high-fiber meals for your child." B. "Everyone in the home should practice good hand hygiene." C. "You should plan to homeschool your child." D. "Avoid routine immunizations."

"Everyone in the home should practice good hand hygiene."

A nurse is reinforcing teaching with the family of a 6 month old infant about ways to stimulate language development. Which of the following instructions should the nurse include? A. "Explain what you are doing to the infant while providing care." B. "Promote fine-motor development of the tongue with the use of a pacifier several times each day." C. "Exercise jaw muscles with foods that require chewing such as hot dogs and carrots." D. "Leave a television playing in the child's room during nap time."

"Explain what you are doing to the infant while providing care."

A school nurse is reinforcing teaching with an adolescent who has type 1 diabetes mellitus. Which of the following responses by the adolescent indicates an understanding of the teaching? (select all that apply) A. "I should eat extra food on busy days when I am more active." B. "I should wait 2 hours after eating before going swimming with my friends." C. "I should increase my intake of sugar-free fluids when I am sick." D. "I should eat a snack 30 minutes before my baseball games start." E. "I should have a 16-ounce sports drink if I start feeling weak or shaky."

1. "I should eat extra food on busy days when I am more active." 2. "I should increase my intake of sugar-free fluids when I am sick." 3. "I should eat a snack 30 minutes before my baseball games start."

A nurse in a community center is assisting with an in-service to a group of guardians on management of airway obstructions in toddlers. Which of the following responses by one of the caregivers indicates an understanding of the information? (select all that apply) a. "I will push on my child's abdomen." b. "I will hyperextend my child's head to open the airway." c. "I will use my finger to check my child's mouth for objects." d. "I will use my finger to check my child's mouth for objects." e. "I will place my child in my car and take them to the closest emergency facility."

1. "I will push on my child's abdomen." 2. "I will place my child in my car and take them to the closest emergency facility."

A nurse is reinforcing teaching with the guardian of a child who has Kawasaki disease. Which of the following statements by the guardian indicate an understanding of the teaching? (select all that apply) A. "My child will likely be irritable for the next few weeks." B. "I will notify my child's doctor if the skin on her hands or feet begins to peel." C. "I will make sure my child does not receive any live vaccines for at least 18 months." D. "I will keep a record of my child's temperature until she has no fever for several days." E. "My child will have joint stiffness primarily at the end of the day."

1. "My child will likely be irritable for the next few weeks." 2. "I will make sure my child does not receive any live vaccines for at least 18 months." 3. "I will keep a record of my child's temperature until she has no fever for several days."

A nurse is collecting data from a child who has Meckel's diverticulum. Which of the following manifestations should the nurse expect? (select all that apply) A. Abdominal pain B. Fever C. Mucus and blood in stools D. Vomiting E. Rapid, shallow breathing

1. Abdominal pain 2. Mucus and blood in stools

A nurse is collecting data from a 24 month old toddler at the local health department. The nurse should expect which of the following findings? (Select all that apply) A. 8 deciduous teeth B. Ability to build a tower of 6 blocks C. Vocabulary of 10 to 20 words D. Slightly bowed or curved appearance of the legs E. Head circumference exceeds chest circumference

1. Ability to build a tower of 6 blocks 2. Slightly bowed or curved appearance of the legs

A nurse is caring for a child who has bronchiolitis. Which of the following actions should the nurse take? A. Administer oral prednisone B. Initiate chest percussion and postural drainage C. Administer humidified oxygen D. Suction the nasopharynx as needed E. Administer oral penicillin

1. Administer humidified oxygen 2. Suction the nasopharynx as needed

A nurse is reinforcing teaching with the teacher of a child who has attention-deficit/hyperactivity disorder (ADHD). Which of the following classroom strategies should the nurse include? (select all that apply) a. Eliminate testing b. Allow for regular breaks c. Combine verbal instruction with visual cues d. Establish consistent classroom rules e. Increase stimulu in the environment

1. Allow for regular breaks 2. Combine verbal instruction with visual cues 3. Establish consistent classroom rules

A nurse is contributing to the plan of care for an infant who has diaper dermatitis. Which of the following interventions should the nurse include? (select all that apply) A. Apply talcum powder with every diaper change B. Allow the buttocks to air dry C. Use commercial baby wipes to cleanse the area D. Use cloth diapers until the rash is gone E. Apply zinc oxide ointment to the affected area

1. Allow the buttocks to air dry 2 Apply zinc oxide ointment to the affected area

A nurse is collecting data from a child who has leukemia. Which of the following are early manifestations of leukemia? (select all that apply) A. Hematuria B. Anorexia C. Petechiae D. Ulcerations in the mouth E. Unsteady gait

1. Anorexia 2. Petechiae 3. Unsteady gait

A nurse is caring for a preschooler who has a vesicular, honey-colored, crusty region around the nose and mouth and has been diagnosed with impetigo contagiosa. Which of the following instructions should the nurse plan to reinforce with the parents? (select all that apply) A. Apply a topical antibacterial ointment to the lesions B. Wash the child's bed linens daily with hot water C. Administer acyclovir oral suspension to prevent recurrence D. Allow the crust covering the infected lesions to remain intact E. Wash hands before and after contact with the affected area

1. Apply a topical antibacterial ointment to the lesions 2. Wash the child's bed linens daily with hot water 3. Wash hands before and after contact with the affected area

A school nurse is providing care to a child who has a nosebleed. Which of the following actions should the nurse take? (select all that apply) A. Place the child in a supine position B. Apply pressure to the child's nose using the thumb and forefinger C. Have the child tilt his head back D. Apply a warm cloth to the bridge of the child's nose E. Keep the child calm

1. Apply pressure to the child's nose using the thumb and forefinger 2. Keep the child calm

A nurse is reinforcing teaching with the guardian of an infant about administration of oral medications. Which of the following should the nurse include in the teaching? (Select all that apply) A. Use a universal dropper for medication administration B. Ask the pharmacy to add flavoring to the medication C. Add the medication to a formula bottle before feeding D. Use the nipple of a bottle to administer the medication E. Hold the infant in an semi-reclining position

1. Ask the pharmacy to add flavoring to the medication 2. Use the nipple of a bottle to administer the medication 3. Hold the infant in an semi-reclining position

A nurse is caring for an infant who has manifestations of acute otitis media (AOM). The nurse should identify that which of the following factors places the infant at risk for otitis media? (select all that apply) A. breastfeeds without formula supplementation B. Attends day care 4 days per week C. Immunizations are up to date D. History of a cleft palate repair E. Parents smoke cigarettes outside

1. Attends day care 4 days per week 2. History of a cleft palate repair 3. Parents smoke cigarettes outside

A nurse is reinforcing teaching with a group of parents about preventing insect bites. Which of the following information should the nurse include? (select all that apply) A. Wear perfumes when outside B. Avoid areas of tall grass C. Wear bright-colored clothing D. Wear insect repellent E. Check house pets frequently

1. Avoid areas of tall grass 2. Wear insect repellent 3. Check house pets frequently

A nurse is reinforcing teaching with the guardian of a child who has a urinary tract infection. Which of the following instructions should the nurse include? (select all that apply) A. Wear nylon underpants B. Avoid bubble baths C. Empty bladder completely with each void D. Watch for manifestations of infection E. Wipe perineal area back to front

1. Avoid bubble baths 2. Empty bladder completely with each void 3. Watch for manifestations of infection

A nurse is caring for a child who has cerebral palsy and is experiencing muscle spams. Which of the following medications should the nurse expect the provider to prescribe? (select all that apply) A. Baclofen B. Diazepam C. Oxybutynin D. Methotrexate E. Prednisone

1. Baclofen 2. Diazepam

A nurse is caring for an infant and notices an audible click in their left hip. Which of the following diagnostic test should the nurse expect the provider to perform? (select all that apply) A. Barlow test B. Babinski reflex C. Manipulation of foot and ankle D. Ortolani test E. Ponseti method

1. Barlow test 2. Ortolani test

A nurse is assisting with providing anticipatory guidance to the caregiver of a 13 year old adolescent. Which of the following screenings should the nurse recommend for the adolescent? (select all that apply) A. Body mass index B. Blood lead level C. 24 hr dietary recall D. Weight E. Scoliosis

1. Body mass index 2. Weight 3. Scoliosis

A nurse is caring for a child who has short stature. Which of the following diagnostic tests should the nurse expect to confirm a growth hormone (GH) deficiency? (select all that apply) A. CT scan of the head B. Skeletal x-rays C. GH Stimulation test D. Blood IGF-1 E. DNA testing

1. CT scan of the head 2. Skeletal x-rays 3. GH Stimulation test 4. Blood IGF-1

A nurse is preparing to administer medication to a toddler. Which of the following actions should the nurse take? (select all that apply) A. Identify the toddler by asking the caregiver B. Tell the caregiver to administer the medication C. Calculate the safe dosage D. Ask the toddler to pick a toy to hold during administration E. Offer juice after medication

1. Calculate the safe dosage 2. Ask the toddler to pick a toy to hold during administration 3. Offer juice after medication

A nurse is caring for a child who is in skeletal traction. Which of the following actions should the nurse take? (select all that apply) A. Remove the weights to reposition the client B. Check the child's position every 4 hr C. Monitor pin sites every 4 hr D. Ensure the weights are hanging freely E. Ensure the rope's knot he is in contact with the pulley

1. Check the child's position every 4 hr 2. Monitor pin sites every 4 hr 3. Ensure the weights are hanging freely

A nurse is reinforcing teaching with a guardian about posttraumatic stress disorder (PTSD). Which of the following information should the nurse include? (select all that apply) a. Children who have PTSD can benefit from psychotherapy b. A manifestation of PTSD is phobias c. Personality disorders are a complication of PTSD d. PTSD develops following a traumatic event e. There are six stages of PTSD

1. Children who have PTSD can benefit from psychotherapy 2. A manifestation of PTSD is phobias 3. Personality disorder are a complication of PTSD

A nurse is checking the trigeminal nerve of an adolescent client. Which of the following responses should the expect? (select all that apply) A. Clenching teeth together tightly B. Recognizing sour tastes on the back of the tongue C. Identifying smells through each nostril D. Detecting facial touches with eyes closed E. Looking down and in with the eyes

1. Clenching teeth together tightly 2. Detecting facial touches with eyes closed

A nurse is collecting data from an infant who has heart failure. Which of the following findings should the nurse expect? (select all that apply) A. Bradycardia B. Cool extremities C. Peripheral edema D. Increased urinary output E. Nasal flaring

1. Cool extremities 2. Peripheral edema 3. Nasal flaring

A nurse is caring for a child who has a fracture. Which of the following findings should the nurse expect? (Select all that apply) A. Crepitus B. Edema C. Pain D. Fever E. Ecchymosis

1. Crepitus 2. Edema 3. Pain 4. Ecchymosis

A nurse is collecting data from a child who has type 1 diabetes mellitus. Which of the following manifestations indicate of diabetic ketoacidosis? (select all that apply) A. Blood glucose 58 mg/dL B. Weight gain C. Dehydration D. Mental confusion E. Fruity breath

1. Dehydration 2. Mental confusion 3. Fruity breath

A nurse is reinforcing teaching with the guardian of a child who has growth hormone deficiency. Which of the following complications of untreated growth hormone deficiency should the nurse include? (select all that apply) A. Delayed sexual development B. Premature aging C. Advanced bone age D. Short stature E. Increased epiphyseal closure

1. Delayed sexual development 2. Premature aging 3. Short stature

A nurse in a community center is reinforcing teaching about poison control with a group of parents. A parent asks what to do if a child ingests a large quantity of acetaminophen. Identify the sequence of actions the nurse should recommend to the parent. A. identify the medication and dosage strength B. Determine if the child is breathing C. Empty the child's mouth of remaining pills and residue D. Call a poison control center

1. Determine if the child is breathing 2. Empty the child's mouth of remaining pills and residue 3. identify the medication and dosage strength 4. Call a poison control center

A nurse providing anticipatory guidance to the adoptive parents of a toddler. Which of the following information should the nurse include? (Select all that apply) A. Develop food habits that will prevent dental caries B. Meeting caloric needs results in an increased appetite C. Expression of bedtime fears is common D. Expect behaviors associated with negativism and ritualism E. Annual screenings for phenylketonuria are important

1. Develop food habits that will prevent dental caries 2. Expression of bedtime fears is common 3. Expect behaviors associated with negativism and ritualism

A nurse is caring for a child who is dying. Which of the following are findings of impending death? select all that apply) A. Heightened sense of hearing B. Tachycardia C. Difficulty swallowing D. Sensation of being cold E. Cheyne-Stokes respirations

1. Difficulty swallowing 2 Cheyne-Stokes respirations

A nurse is collecting data from a child who has epiglottis. Which of the following findings should the nurse expect? (select all that apply) A. Hoarseness B. Difficulty swallowing C. Low-grade fever D. Drooling E. Dry, barking cough F. Stridor

1. Difficulty swallowing 2. Drooling 3. Stridor

A nurse is conducting a well-child visit with a 5 year old child who is up to date with current immunizations. Which of the following immunizations should the nurse plan to administer to the child? (select all that apply) A. Diphtheria, tetanus, pertussis (DTaP) B. Inactivated poliovirus (IPV) C. Measles, mumps, rubella (MMR) D. Pneumococcal (PCV) E. Haemophilus influenzae type B (Hib)

1. Diphtheria, tetanus, pertussis (DTaP) 2. Inactivated poliovirus (IPV) 3. Measles, mumps, rubella (MMR)

A nurse is assisting with the care of a 4 year old child who is prescribed an IV medication preoperatively. Which of the following techniques should the nurse use to assist the child to cope with this procedure (select all that apply) A. Discuss benefits of the procedure B. Provide the child with a detailed explanation of the procedure C. Implement interactive sessions of 30 min D. Give the child needless IV supplies to play with E. Allow the child to perform the procedure with a doll

1. Discuss benefits of the procedure 2. Give the child needless IV supplies to play with 3. Allow the child to perform the procedure with a doll

A nurse in an urgent care clinic is admitting an infant who experienced a life threatening event. Which of the following prescriptions by the provider should the nurse anticipate? (select all that apply) a. Electroencephalogram b. Electrocardiogram c. Urine culture d. Arterial blood gases e. Blood culture

1. Electroencephalogram 2. Electrocardiogram 3. Blood culture

A nurse is caring for a child who sustained a fracture. Which of the following actions should the nurse take? (select all that apply) A. Place a heat pack on the site of injury B. Elevate the affected limb C. Check neurovascular status frequently D. Encourage ROM of the affected limb E. Stabilize the injury

1. Elevate the affected limb 2. Check neurovascular status frequently 3. Stabilize the injury

A nurse is collecting data from a child who has rhabdomyosarcoma of the nasopharynx. Which of the following are manifestations of rhabdomyosarcoma? (select all that apply) A. Enlarged neck lymph nodes B. Pain C. Vomiting D. Epistaxis E. Diplopia

1. Enlarged neck lymph nodes 2. Pain 3. Epistaxis

A nurse is collecting data from a child who has rheumatic fever. Which of the following findings should the nurse expect? (select all that apply) A. Erythema marginatum (rash) B. Continuous joint pain of the digits C. Tender, subcutaneous nodules D. Decreased erythrocyte sedimentation rate E. Elevated C-reactive protein

1. Erythema marginatum (rash) 2. Elevated C-reactive protein

A nurse on a pediatric unit is caring for a toddler. Which of the following behaviors is an effect of hospitalization? (select all that apply) A. Believes the experience is a punishment B. Experiences separation anxiety C. Displays intense emotions D. Exhibits regressive behaviors E. Manifests disturbance in body image

1. Experiences separation anxiety 2. Displays intense emotions 3. Exhibits regressive behaviors

A nurse is preparing to assist the charge nurse with discussing risk factors for asthma with a group newly licensed nurses. Which of the following conditions should the nurse include in the teaching? A. Family history of asthma B. Family history of allergies C. Exposure to smoke D. Low birth weight E. Being underweight

1. Family history of asthma 2. Family history of allergies 3. Exposure to smoke 4. Low birth weight

A nurse is reinforcing teaching with a group of caregivers about the risk factors for seizures. Which of the following factors should the nurse include? (select all that apply) A. Febrile episodes B. Hypoglycemia C. Sodium imbalances D. Low blood lead levels E. Presence of diphtheria

1. Febrile episodes 2. Hypoglycemia 3. Sodium imbalances

A nurse is collecting date from a child who has a rotavirus infection. Which of the following are expected findings? (Select all that apply) A. Fever B. Vomiting C. Water stools D. Bloody stools E. Confusion

1. Fever 2. Vomiting 3. Water stools

A nurse is collecting data during a developmental screening on a 10 month old infant. Which of the fine motor skills should the nurse expect the infant to perform? (select all that apply) A. Grasp the rattle by the handle B. Try building a two block tower C. Use a crude pincer grasp D. Place objects into a container E. Walks with one hand held

1. Grasp the rattle by the handle 2. Use a crude pincer grasp

A nurse is collecting data from a child who has myopia. Which of the following findings should the nurse expect? (Select all that apply) A. Headaches B. Photophobia C. Difficulty reading D. Difficult focusing on close objects E. Poor school performance

1. Headaches 2. Difficulty reading 3. Poor school performance

A nurse is reinforcing teaching with a group of toddlers about measures to reduce the risk of choking. Which of the following foods should the nurse teach increases the risk of choking in toddlers? (select all that apply) A. Hot dogs B. Grapes C. Bagels D. Marshmallows E. Graham crackers

1. Hot dogs 2. Grapes 3. Bagels 4. Marshmallows

A nurse is reinforcing teaching with an adolescent who has diabetes mellitus about manifestations of hypoglycemia. Which of the following findings should the nurse include? (select all that apply) A. Increased urination B. Hunger C. Poor skin turgor D. Irritability E. Sweating and pallor F. Kussmaul respirations

1. Hunger 2. Irritability 3. Sweating and pallor

A nurse in an emergency department is assisting with the care of a 4 year old child who ingested toilet bowl cleaner. The child has hemoptysis, is crying, and states, "It burns." Which of the following actions should the nurse take to assist with the child's care? (select all that apply) A. Identify how much cleaner was in the bottle B. Administer activated charcoal C. Gather supplies for gastric lavage D. Assist with the insertion of an IV for morphine administration E. Apply a pulse oximeter

1. Identify how much cleaner was in the bottle 2. Apply a pulse oximeter

A nurse is assisting with conducting a well child visit with a child who is scheduled to receive the recommended immunizations for 11-12 year olds. Which of the following immunizations should the nurse administer? (select all that apply) A. Inactivated influenza (IIV) B. Pneumococcal (PCV) C. Meningococcal (MenB-4C) D. Tetanus and diphtheria toxoids and pertussis (Tdap) E. Rotavirus (RV)

1. Inactivated influenza (IIV) 2. Meningococcal (MenB-4C) 3. Tetanus and diphtheria toxoids and pertussis (Tdap)

A nurse is planning to administer recommended immunizations to a 4 year old child. Which of the following vaccines should the nurse plan to give? (select all that apply) A. Inactivated poliovirus (IPV) B. Haemophilus influenzae type b (Hib) C. Measles, mumps, rubella (MMR) D. Varicella (VAR) E. Hepatitis B (HeB) F. Diphtheria, tetanus, and acellular pertussis (DTaP)

1. Inactivated poliovirus (IPV) 2. Measles, mumps, rubella (MMR) 3. Varicella (VAR) 4. Diphtheria, tetanus, and acellular pertussis (DTaP)

A nurse is collecting data from a client who has major burns and suspected septic shock. Which of the following findings should the nurse expect? (select all that apply) A. Increased body temperature B. Altered sensorium C. Decreased capillary refill time D. Decreased urine output E. Increased bowel sounds

1. Increased body temperature 2. Altered sensorium 3. Decreased urine output

A nurse is collecting data from an infant who has a suspected urinary tract infection. Which of the following findings should the nurse expect? (select all that apply) A. Increase in hunger B. Irritability C. Decrease in urination D. Vomiting E. Fever

1. Irritability 2. Vomiting 3. Fever

A nurse is reinforcing teaching with a group of parents about Salmonella. Which of the following information should the nurse include? (Select all that apply) A. Incubation period is nonspecific B. It is a bacterial infection C. Bloody diarrhea is common D. Transmission can be from house pets E. Antibiotics are used for treatment

1. It is a bacterial infection 2. Bloody diarrhea is common 3. Transmission can be from house pets

A nurse is caring for a child who has severely symptomatic HIV. Which of the following findings should the nurse expect? (select all that apply) A. Kaposi's sarcoma B. Hepatitis C. Wasting syndrome D. Pulmonary candidiasis E. Cardiomyopathy

1. Kaposi's sarcoma 2. Wasting syndrome 3. Pulmonary candidiasis

A nurse is caring for a child who has absence seizures. Which of the following findings should the nurse expect? (select all that apply) A. Loss of consciousness B. Appearance of daydreaming C. Dropping help objects D. Falling to the floor E. Having a piercing cry

1. Loss of consciousness 2. Appearance of daydreaming 3. Dropping help objects

A nurse is collecting data from an infant. Which of the following are findings of pain in an infant? (Select all that apply) A. Pursed lips B. Loud cry C. Lowered eyebrows D. Rigid body E. Pushes away stimulus

1. Loud cry 2. Lowered eyebrows 3. Rigid body

A nurse is assisting with performing family data collection. Which of the following should the nurse include? A. Medical history B. Parents' education level C. Child's physical growth D. Support systems E. Stressors

1. Medical history 2. Parents' education level 3. Support systems 4. Stressors

A nurse is reinforcing teaching about sick-day management with a parent of a child who has type 1 diabetes mellitus. Which of the following instructions should the nurse include? (select all that apply) A. Monitor blood glucose levels every 3 hr B. Discontinue taking insulin until feeling better C. Drink 8 oz of fruit juice every hour D. Test urine for ketones E. Call the provider if blood glucose is greater than 240 mg/dL

1. Monitor blood glucose levels every 3 hr 2. Test urine for ketones 3. Call the provider if blood glucose is greater than 240 mg/dL

A nurse is assisting with the care for a child who has thrombocytopenia following chemotherapy. Which of the following actions should the nurse take? (select all that apply) A. Monitor for manifestations of bleeding B. Administer routine immunizations C. Obtain rectal temperatures D. Avoid peripheral venipunctures E. Limit visitors

1. Monitor for manifestations of bleeding 2. Avoid peripheral venipunctures

A nurse is collecting data from a child who has muscular dystrophy. Which of the following findings should the nurse expect? (Select all that apply) A. Purposeless, involuntary, abnormal movements B. Spinal defect and saclike protrusion C. Muscular weakness in lower extremities D. Unsteady, wide-based or waddling gait E. upward slant to the eyes

1. Muscular weakness in lower extremities 2. Unsteady, wide-based or waddling gait

A nurse is reviewing cerebrospinal fluid analysis for a client who has suspected meningitis. Which of the following findings should the nurse identify as indicating viral meningitis? (Select all that apply) A. Negative Gram stain B. Normal glucose content C. Turbid and cloudy color D. Decreased WBC count E. Normal protein content

1. Negative Gram stain 2. Normal glucose content 3. Normal protein content

A nurse is caring for a child who is receiving a bronchodilator medication by nebulized aerosol therapy. Which of the following actions should the nurse take? (select all that apply) A. Instruct the child that the treatment will last 30 min B. Obtain vital signs prior to the procedure C. tell the child to take slow deep breaths D. Determine if the child should use a mask E. Attach the device to an air source

1. Obtain vital signs prior to the procedure 2. tell the child to take slow deep breaths 3. Determine if the child should use a mask 4. Attach the device to an air source

A nurse is reinforcing teaching with the guardian of a child who has HIV. Which of the following information should the nurse include? (select all that apply) A. Obtain yearly influenza vaccination B. Monitor a fever for 24 hr before seeking medical care C. Avoid individuals who have colds D. Provide nutritional supplements E. Administer aspirin for pain

1. Obtain yearly influenza vaccination 2. Avoid individuals who have colds 3. Provide nutritional supplements

A nurse is contributing to the plan of care for an infant who is experiencing pain. Which of the following interventions should the nurse include in the plan of care? (select all that apply) A. Offer a pacifier B. Use guided imagery C. Use swaddling D. Initiate a behavioral contact E. Encourage kangaroo care

1. Offer a pacifier 2. Use swaddling 3. Initiate a behavioral contact

A nurse is reinforcing teaching with the guardian of an infant about gastrointestinal reflux disease. Which of the following instructions should the nurse include? (select all that apply) A. Offer frequent feedings B. Thicken formula with rice cereal C. Use a bottle with a one way valve D. Position baby upright after feedings E. Use a wide-based nipple for feedings

1. Offer frequent feedings 2. Thicken formula with rice cereal 3. Position baby upright after feedings

A nurse is assisting with the care for a child who has oral mucositis. Which of the following actions should the nurse take? (select all that apply) A. Swab the mucosa with lemon glycerin swabs B. Apply viscous lidocaine C. Offer soft foods D. Use a soft, disposable toothbrush for oral care E. Encourage gargling with a warm saline mouthwash

1. Offer soft foods 2. Use a soft, disposable toothbrush for oral care 3. Encourage gargling with a warm saline mouthwash

A nurse is assisting with the admission of a child who has HIV. The nurse should identify which of the following findings as an indication that the child is in the mildly symptomatic category of the infection? (select all that apply) A. Herpes zoster B. Anemia C. Oral candidiasis D. Hepatomegaly E. Lympadenopathy

1. Oral candidiasis 2. Hepatomegaly 3. Lympadenopathy

nurse is caring for a client who has rubeola. The nurse should monitor for which of the following complications? (select all that apply) A. Otitis media B. Constipation C. Laryngitis D. Arthralgia E. Syncope

1. Otitis media 2. Laryngitis

A nurse is collecting date from an infant who has scabies. Which of the following findings should the nurse expect? (select all that apply) A. Presence of nits on the hair shaft B. Pencil-like marks on hands C. Blisters on the soles of the feet D. Small, red bumps on the scalp E. Pimples on the trunk

1. Pencil-like marks on hands 2. Blisters on the soles of the feet 3. Pimples on the trunk

A nurse is contributing to the plan of care for a child who has asthma. Which of the following interventions should the nurse include in the plan of care? (Select all that apply) A. Perform chest percussion B. Place the child in an upright position C. Monitor oxygen saturation D. Administer bronchodilators E. Administer dornase alfa daily

1. Place the child in an upright position 2. Monitor oxygen saturation 3. Administer bronchodilators

A nurse is assisting with the development of an in-service about viral and bacterial meningitis. The nurse should include that the introduction of which of the following immunizations decreased the incidence of bacterial meningitis in children? (select all that apply) A. Inactivated polio vaccine (IPV) B. Pneumococcal conjugate vaccine (PCV) C. Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) D. Haemophilus influenzae type B (Hib) vaccine E. Inactivated influenza vaccine (IIV)

1. Pneumococcal conjugate vaccine (PCV) 2. Haemophilus influenzae type B (Hib) vaccine

A nurse is collecting data during a well-baby visit with a 4 month old infant. Which of the following immunizations should the nurse plan to administer to the infant? (select all that apply) A. Measles, mumps, rubella (MMR) B. Polio (IPV) C. Pneumococcal vaccine (PCV) D. Varicella E. Rotavirus vaccine (RV)

1. Polio (IPV) 2. Pneumococcal vaccine (PCV) 3. Rotavirus vaccine (RV)

A nurse is caring for an infant who has ambiguous genitalia. Which of the following actions should the nurse take? (select all that apply) A. Prepare the infant for surgery B. Test the infant's adrenal function C. Cover the genitals with a sterile dressing D. Refer to the family for genetic counseling E. Explain the need for a chromosomal analysis

1. Prepare the infant for surgery 2. Test the infant's adrenal function 3. Refer to the family for genetic counseling 4. Explain the need for a chromosomal analysis

A nurse is providing reinforcement teaching about epistaxis to the parent of a school-age child. Which of the following should the nurse include as an action to take when managing an episode of epistaxis? (select all that apply) A. Press the nares together for at least 10 min B. Breathe through the nose until the bleeding stops C. Pack cotton or tissue into the naris that is bleeding D. Apply a cold cloth across the bridge of the nose E. Insert petroleum into the naris after the bleeding stops

1. Press the nares together for at least 10 min 2. Apply a cold cloth across the bridge of the nose

A nurse is collecting data from an infant who has hypertrophic pyloric stenosis. Which of the following manifestations should the nurse expect? (select all that apply) A. Projectile vomiting B. Dry mucus membranes C. Currant jelly stools D. Sausage-shaped abdominal mass E. Constant hunger

1. Projectile vomiting 2. Dry mucus membranes 3. Constant hunger

A nurse is reinforcing teaching with a group of caregivers about possible manifestations of Down syndrome. Which of the following findings should the nurse include? (Select all that apply) A. A large head with bulging fontanels B. Larger ears that are set back C. Protruding abdomen D. Broad, short feet and hands E. Hypotonia

1. Protruding abdomen 2. Broad, short feet and hands 3. Hypotonia

A nurse is reinforcing discharge teaching with the guardians of a school-age child who has juvenile idiopathic arthritis. Which of the following instructions should the nurse include? (select all that apply) A. Provide extra time for completion of ADLs B. Use cold compresses for joint pain C. Take ibuprofen on an empty stomach D. Remain home during periods of exacerbation E. Perform range-of-motion exercises

1. Provide extra time for completion of ADLs 2. Perform range-of-motion exercises

A nurse is assisting with preparing a toddler for an intravenous catheter insertion using atraumatic care. Which of the following actions should the nurse take (select all that apply) A. Reinforce the procedure using the child's favorite toy B. Ask the guardians to leave during the procedure C. Assist with performing the procedure with the child in his bed D. Allow the child to make one choice regarding the procedure E. Apply lidocaine and prilocaine cream to three potential insertion sites

1. Reinforce the procedure using the child's favorite toy 2. Allow the child to make one choice regarding the procedure 3. Apply lidocaine and prilocaine cream to three potential insertion sites

A nurse often cares for children who are dying. Which of the following are actions for the nurse to take to maintain professional effectiveness? select all that apply) A. Remain in contact with the family after their loss B. Develop a professional support system C. Take time off from work D. Suggest that a hospital representative attend the funeral E. Demonstrate feelings of sympathy toward the family.

1. Remain in contact with the family after their loss 2. Develop a professional support system 3. Take time off from work

A nurse is caring for a child who has contact dermatitis due to poison ivy exposure. Which of the following actions should the nurse take? (select all that apply) A. Remove the clothing over the rash B. Initiate contact isolation precautions while the rash is present C. Expose the rash to a heat lamp for 15 min D. Cleanse the affected areas with hydrogen peroxide solution E. Apply calamine lotion to the skin

1. Remove the clothing over the rash 2. Apply calamine lotion to the skin

A nurse is collecting data from an infant who has acute otitis media. Which of the following findings should the nurse expect? (select all that apply) A. Decreased pain in the supine position B. Rolling head side to side C. Loss of appetite D. Increased sensitivity to sound E. Crying

1. Rolling head side to side 2. Loss of appetite 3. Crying

A nurse is planning to administer recommended immunizations to a 2 month old infant. Which of the following vaccines should the nurse plan to give? (select all that apply) A. Rotavirus (RV) B. Diphtheria, tetanus, and acellular pertussis (DTaP) C. Haemophilus influenzae type b (Hib) D. Hepatitis A (HepA) E. Pneumococcal conjugate (PCV13) F. Inactivated poliovirus (IPV)

1. Rotavirus (RV) 2. Diphtheria, tetanus, and acellular pertussis (DTaP) 3. Haemophilus influenzae type b (Hib) 4. Pneumococcal conjugate (PCV13) 5. Inactivated poliovirus (IPV)

A nurse is reinforcing teaching with a group of family members about complications of communicable diseases. Which of the following communicable diseases can lead to pneumonia? (select all that apply) A. Rubella (German measles) B. Rubeola (measles) C. Pertussis (whooping cough) D. Varicella (chicken pox) E. Mumps

1. Rubeola (measles) 2. Pertussis (whooping cough) 3. Varicella (chicken pox)

A nurse is collecting data from a client who has pertussis. Which of the following findings should the nurse expect? (select all that apply) A. Runny nose B. mild fever C. Cough with whooping sound D. Swollen salivary glands E. red rash

1. Runny nose 2. mild fever 3. Cough with whooping sound

A nurse is reinforcing teaching a group of caregivers about E. coli. Which of the following information should the nurse include? (select all that apply) A. Severe abdominal cramping occurs B. Watery diarrhea is present for more than 5 days C. It can lead to hemolytic uremic syndrome D. It is a foodborne pathogen E. Antibiotics are given for treatment

1. Severe abdominal cramping occurs 2. It can lead to hemolytic uremic syndrome 3. It is a foodborne pathogen

A nurse is reinforcing teaching with an adolescent to self-administer a corticosteroid medication using a metered-dose inhaler (MDI). Which of the following instructions should the nurse include (select all that apply) A. Shake the device prior to use B. Rinse and expectorate after administration C. Inhale slowly with medication administration D. Exhale quickly after medication administration E. Wait 30 seconds between puffs

1. Shake the device prior to use 2. Rinse and expectorate after administration 3. Inhale slowly with medication administration

A nurse is reinforcing teaching with a school-aged child who has asthma about how to use a metered-dose inhaler. In which order should the nurse instruct the child to perform the following steps and evaluate return demonstrations? A. Shake the inhaler while holding it upright B. Position the mouthpiece in the mouth C. Hold the breath for 5 to 10 seconds D. Slowly inhale the medication

1. Shake the inhaler while holding it upright 2. Position the mouthpiece in the mouth 3. Slowly inhale the medication 4. Hold the breath for 5 to 10 seconds

A nurse is caring for a child who is experiencing respiratory distress. Which of the following findings are early manifestations of respiratory distress? (select all that apply) a. Bradypnea b. Peripheral cyanosis c. Tachycardia d. Diaphoresis e. Restlessness

1. Tachycardia 2. Diaphoresis 3. Restlessness

A nurse is reinforcing discharge teaching with a client who is postpartum and plans to breastfeed her infant. Which of the following pieces of information should the nurse reinforce with the client? (Select all that apply) A. Schedule feedings every 4 hr B. Offer supplemental formula every other feeding during her first week C. Thaw frozen breast milk with warm water D. Massage breast milk onto the nipples after breastfeeding E. Frequent swallowing by the infant indicates adequate suckling

1. Thaw frozen breast milk with warm water 2. Massage breast milk onto the nipples after breastfeeding 3. Frequent swallowing by the infant indicates adequate suckling

A nurse is assisting with a development screening on an 18 month old. Which of the following skills should the toddler be able to perform? (Select all that apply) A. Build a tower with six blocks B. Throw a ball overhand C. Walk up and down stairs D. Stand on one foot for a few seconds E. Use a spoon without rotation

1. Throw a ball overhand 2. Use a spoon without rotation

A nurse is assisting with the admission of a child who has cystic fibrosis. Which of the following medications should the nurse expect the provider to prescribe? (select all that apply) A. Tobramycin B. Loperamide C. Fat-soluble vitamins D. Albuterol E. Dornase alfa

1. Tobramycin 2. Fat-soluble vitamins 3. Albuterol 4. Dornase alfa

A nurse is contributing to the plan of care for a child who has tinea capitis. Which of the following interventions should the nurse include? (select all that apply) A. Treat infected house pets B. Use selenium sulfide shampoo C. Cleanse area with Burrow solution D. Administer antiviral medication E. Use moist, warm compresses

1. Treat infected house pets 2. Use selenium sulfide shampoo

A nurse is caring for a client who has a skin graft. Which of the following findings indicate infection? (select all that apply) A. Pink color to subcutaneous fat B. Unstable body temperature C. Generation of granulation tissue D. Subeschar hemorrhage E. Change in skin color around the affected area.

1. Unstable body temperature 2. Subeschar hemorrhage 3. Change in skin color around the affected area.

A nurse is caring for an infant who has obstructive uropathy. Which of the following findings should the nurse expect? (select all that apply) A. Decreased urine flow B. Urinary tract infection C. History of maternal polyhydramnios D. Concentrated urine E. Hydronephrosis

1. Urinary tract infection 2. Hydronephrosis

A nurse is collecting data from a child who has nephrotic syndrome. Which of the following findings should the nurse expect? (select all that apply) A. Urine dipstick +2 protein B. Edema in the ankles C. Hyperlipidemia D. Polyuria E. Anorexia

1. Urine dipstick +2 protein 2. Edema in the ankles 3. Hyperlipidemia 4. Anorexia

A nurse is collecting screening data from a toddler for possible hearing loss. Which of the following findings are indications of a hearing impairment? (select all that apply) A. Uses monotone speech B. Speaks loudly C. Repeats sentences D. Appears shy E. Is overly attentive to the surroundings

1. Uses monotone speech 2. Speaks loudly 3. Appears shy

A nurse is preparing to reinforce treatment options with the guardian of a child who has worsening seizures. Which of the following treatment options should the nurse include in the discussion? (select all that apply) A. Vagal nerve stimulator B. Additional antiepileptic medications C. Corpus callosotomy D. Focal resection E. Radiation therapy

1. Vagal nerve stimulator 2. Additional antiepileptic medications 3. Corpus callosotomy 4. Focal resection

A nurse is collecting data from an infant who has coarctation of the aorta. Which of the following findings should the nurse expect? (select all that apply) A. Weak femoral pulses B. Cool skin of lower extremities C. Severe cyanosis D. Clubbing of the fingers E. Low blood pressure

1. Weak femoral pulses 2. Cool skin of lower extremities 3. Low blood pressure

A nurse is assisting with teaching a course about safety during the school age. Which of the following information should the nurse include in the course? (Select all that apply) A. Gating stairs at the top and bottom B. Wearing helmets when riding bicycles or skateboarding C. Riding safely in bed of pickup trucks D. Implementing firearm safety E. Wearing seat belts

1. Wearing helmets when riding bicycles or skateboarding 2. Implementing firearm safety 3. Wearing seat belts

A nurse is collecting data from a child who has a cystic fibrosis. Which of the following findings should the nurse expect? (select all that apply) A. Wheezing B. Clubbing of fingers and toes C. Barrel-shaped chest D. Thin, water mucus E. Rapid growth spurts

1. Wheezing 2. Clubbing of fingers and toes 3. Barrel-shaped chest

A nurse is collecting data from a child who has asthma. Which of the following are indications of deterioration in the child's respiratory status? (select all that apply) A. Oxygen saturation 95% B. Wheezing C. Retraction of sternal muscles D. Warm extremities E. Nasal flaring

1. Wheezing 2. Retraction of sternal muscles 3. Nasal flaring

A nurse is caring for an infant who has biliary atresia. Which of the following manifestations should the nurse expect? (Select all that apply) A. Yellow sclerae B. Rapid weight gain C. Tar-colored stools D. Abdominal distention E. Dark Urine

1. Yellow sclerae 2. Abdominal distention 3. Dark Urine

A nurse is reinforcing teaching with a child who has asthma about how to use a peak flow meter. Which of the following information should the nurse include in the teaching? (select all that apply) A. Zero the meter before each use B. Record the average of the attempts C. Perform three attempts D. Deliver a long, slow breath into the meter E. Sit in a chair with feet on the floor

1. Zero the meter before each use 2. Perform three attempts

A nurse is caring for a male infant who has an epispadias. Which of the following findings should the nurse expect? (select all that apply) A. bladder exstrophy B. Inability to retract foreskin C. widened pubic symphysis D. Urethral opening on the dorsal side of the penis E. Pain

1. bladder exstrophy 2. widened pubic symphysis 3. Urethral opening on the dorsal side of the penis

A nurse is collecting data from a newborn who has congenital hypothyroidism. Which of the following findings should the nurse expect? (select all that apply) a. Hypertonicity b. Cool extremities c. Short neck d. Tachycardia e. Hyperreflexia

1. cool extremities 2. short neck

A nurse is preparing to leave the room after performing nasal suctioning for an infant who has respiratory syncytial virus (RSV). Identify the sequence in which the nurse should remove the following personal protective equipment (PPE). A. Mask B. Gloves C. Gown D. Goggles

1. gloves 2. goggles 3. gown 4. mask

A nurse is collecting data from a child who has Legg-Calve-Perthes disease. Which of the following findings should the nurse expect? (Select all that apply) A. Longer affected leg B. hip stiffness C. back pain D. limited ROM E. limp with walking

1. hip stiffness 2. back pain 3. limited ROM 4. limp with walking

A nurse is reviewing the medical record of a female adolescent client who has primary amenorrhea. Which of the following findings should the nurse identify as a risk factor for this disorder? (select all that apply) A. hypothyroidism B. obesity C. cannabis use D. oral contraceptive use E. emotional stress

1. hypothyroidism 2. cannabis use 3. oral contraceptive use 4. emotional stress

A nurse is collecting data from a child who has acute post-streptococcal glomerulonephritis (APSGN). Which of the following manifestations should the nurse expect? (select all that apply) A. pale urine B. periorbital edema C. ill appearance D. decreased creatinine E. hypertension

1. periorbital edema 2. ill appearance 3. hypertension

A nurse is collecting data from a child who has a urinary tract infection. Which of the following findings should the nurse expect? (select all that apply) A. night sweats B. swelling of the face C. pallor D. pale-colored urine C. fatigue

1. swelling of the face 2. pallor 3. fatigue

A nurse is caring for a child who has a depressive disorder. which of the following findings should the nurse expect? (select all that apply) a. prefers being with peers b. weight loss or gain c. reports low self-esteem d. sleeps more than usual e. hyperactivity

1. weight loss of gain 2. reports low self-esteem 3. sleeps more than usual

A nurse is providing teaching about foods high in fiber to the guardian of a child who has chronic constipation. Which of the following foods should the nurse recommend? A. 1/2 cup whole milk B. 1/2 cup baked beans C. 1 cup green leaf lettuce D. 1 cup apple juice

1/2 cup baked beans

A nurse is caring for a child who adheres to a vegetarian diet and has sustained superficial partial-thickness burns. The nurse should recommend which of the following food choices due to the highest protein content? A. Medium baked potato B. Wheat bagel with 1 tbsp of apricot jam C. Large orange D. 1/2 cup of peanut butter with apple slices

1/2 cup of peanut butter with apple slices

A nurse is caring for a toddler. Which of the following objects should the nurse select from the playroom for this child during hospitalization? A. Small plastic doll with clothes and accessories B. Alphabet flash cards C. Handheld video game D. 10-piece wooden puzzle

10-piece wooden puzzle

A nurse is preparing to administer diphenhydramine 5 mg/kg/day PO divided equally every 8 hours to a school-aged child who weighs 50 lb. Diphenhydramine oral solution 12.5 mg/5 mL is available. How many mL should the nurse administer per dose? (round to the nearest whole number)

15

A nurse is assisting with a nutritional screening for a 12 year old client who weighs 41 kg (90 lb) and has a height of 1.5 m (60 in). Which of the following values is the client's body mass index (BMI)? A. 1.5 B. 3.6 C. 18.2 D. 27.3

18.2

A nurse is collecting data from an infant who has eczema. Which of the following findings should the nurse expect? (select all that apply) A. Generalized distribution of lesions B. Papules C. Ecchymosis in flexural areas D. Crusting lesions E. Keratosis pilaris

1A. Generalized distribution of lesions 2. Papules 3. Crusting lesions

A nurse is preparing to administer ampicillin 600 mg by intermittent IV bolus over 15 minutes. Ampicillin is available as 600 mg in 6 mL (0.9% NaCl). The nurse should set the pump to deliver how many mL/hr? (round to the nearest whole number.)

24

A nurse is caring for a 10 year old child who should reduce his fat intake. Which of the following menu choices should the nurse suggest? A. A hot dog on a whole wheat bun B. 3 oz of baked chicken on a whole wheat roll C. 1/2 cup diced potatoes with scrambled eggs D. A medium blueberry muffin

3 oz of baked chicken on a whole wheat roll

A nurse in a provider's office is collecting data from an infant who was born at 32 weeks of gestation and is now 8 months old. Which of the following developmental ages should the nurse expect the infant to demonstrate? A. 2 months B. 4 months C. 6 months D. 8 months

6 months

A nurse is preparing to administer phenobarbital to a toddler who has a seizure disorder and weighs 10 kg (22 lb). The prescription reads phenobarbital sodium 2.5 mg/kg PO BID. Available is phenobarbital 20 mg/5 mL. How many mL should the nurse administer with each dose? (Round to the nearest hundredth)

6.25

A nurse is caring for a school-age child who has been admitted to the facility in sickle cell crisis. The nurse is measuring the child's oral intake for the shift. The child consumed 4 oz of juice at breakfast. For lunch, the child consumed 6 oz of milk, 6 z of gelatin, and drank 7 oz of water. What is the child's oral intake for this shift in milliliters? (round to the nearest whole number)

690 ml # of oz x 30=mL

A nurse is preparing to administer acetaminophen 240 mg PO daily to a child who has a temperature of 38.9 C (102 F). The amount available is acetaminophen oral solution 160 mg/5 mL. How many mL should the nurse administer per dose? (round to the nearest tenth.

7.5 mL

A nurse is collecting data from a newborn at birth to assisn Apgar scores. At 1 min of age, the newborn is crying vigourously with limbs flexed and a heart rate of 120//min. The newborn's trunk is pink, but his hands and feet are cyanotic, and he cries when the soles of his feet are stimulated. Which of the following Apgar scores should the nurse assign this infant? A. 7 B. 8 C. 9 D. 10

9

A nurse is reinforcing teaching with a 10 year old child who requires crutches for a 2 point gait. Which of the following instructions should the nurse reinforce? A. "In the tripod position, all your weight should be on a leg." B. Advance the left crutch and the right leg at the same time." C. "The crutches should be about 3 inches to the side of the foot when walking." D. "You should maintain a half inch of space between the crutch pad and your armpit."

Advance the left crutch and the right leg at the same time."

A nurse in a provider's office is caring for a school-aged child who is experiencing an acute asthma attack. Which of the following medications should the nurse plan to administer? A. Zafirlukast B. Budesonide C. Montelukast D. Albuterol

Albuterol

A nurse is reinforcing teaching to an adolescent about the appropriate use of their asthma medications. Which of the following medications should the nurse instruct t he client to use as needed before exercise? A. Fluticasone/salmeterol B. Montelukast C. Prednisone D. Albuterol

Albuterol

A school nurse is caring for a child who is experiencing an acute asthma attack. Which of the medications should the nurse prepare to administer? A. Zafirlukast B. Budesonide C. Montelukast D. Albuterol

Albuterol

A nurse is reviewing the risk factors for the development of congenital heart disease with a client who is planning to conceive. Which of the following conditions should the nurse include as a maternal risk factor? A. Preeclampsia B. Alcohol consumption C. Placenta previa D. Late prenatal care

Alcohol consumption

A nurse is collecting data about the visual acuity of a group of school-aged children. Which of the following actions should the nurse take? A. Position each child with their heels at a line that is 6 m (20 ft away from the Snellen chart B. Allow each child to wear his or her glasses during the exam C. Start the screening by covering each child's right eye D. Begin by having each child read the largest line of letters at the top of the Snellen chart

Allow each child to wear his or her glasses during the exam

A nurse is caring for a 5 year old child who has pneumonia and is experiencing a poor appetite. Which of the following interventions should the nurse take? A. Firmly instruct the child to eat a few bites at each meal B. Allow the child to choose foods with a lower nutritional content C. Provide larger food portions in case the child is hungry D. Serve the main course and dessert together

Allow the child to choose foods with a lower nutritional content

A nurse is planning to collect data during a physical examination of a preschooler. Which of the following techniques should the nurse use? A. Give the child the option to take deep breaths while listening to the lungs B. Undress the child during the examination C. Allow the child to inspect the equipment used for the exam D. Instruct the child's parent to step out of the room for the exam

Allow the child to inspect the equipment used for the exam

A nurse is preparing to examine a preschooler during a well-child visit. Which of the following actions should the nurse take to prepare the child? A. Allow the child to role-play using miniature equipment B. Use medical terminology to describe what will happen C. Separate the child from the caregiver during the examination D. Keep medical equipment visible to the child

Allow the child to role-play using miniature equipment

A nurse in a pediatric clinic is preparing to administer an IM vaccine to a preschooler. Which of the following action should the nurse take? A. Ask the preschooler's parents to leave the room before administering the vaccine B. Allow the preschooler to hold a needless syringe during the vaccine C. Give the preschooler a detailed explanation of the purpose of the vaccine D. Reassure the preschooler that the vaccine will feel like a bee sting

Allow the preschooler to hold a needless syringe during the vaccine

A nurse on a pediatric unit is assisting with the plan of care for a preschooler who will be having a surgical procedure in the morning. The child has been crying despite his parents' presence at his bedside. The nurse should recommend engaging the child in therapeutic play for the care plan due to which of the following benefits? A. Decreasing the child's fear of the dark B. Allowing the child to manipulate toy medical equipment C. Providing an opportunity to analyze the child's emotions D. Encouraging parents to engage with their child

Allowing the child to manipulate toy medical equipment

A nurse is caring for a 4-month-old child who has acute otitis media and a fever of 38.3 C (101 F). Which of the following medications should the nurse administer? A. Diphenhydramine B. Furosemide C. Amoxicillin D. Ibuprofen

Amoxicillin

A nurse is reinforcing teaching about nutritional needs with the parents of a 2 year old toddler. Which of the following pieces of information should the nurse include? A. An appropriate serving size of a solid food is 2 tablespoons B. Discourage the toddler from eating with the fingers C. Appetite increases dramatically throughout the toddler years D. Toddlers like to try foods with new tastes and smells

An appropriate serving size of a solid food is 2 tablespoons

A nurse in an urgent care center is reviewing laboratory results for several clients who have manifestations of influenza. Which of the following clients should the nurse report to the provider immediately? A. A school-age child whose urine specific gravity is 1.035 B. A toddler whose BUN is 25 mg/dL and whose creatine is 0.5 mg mg/dL C. An infant whose WBC count is 24,000/mm3 D. An adolescent whose beta human chorionic gonadotropin is positive

An infant whose WBC count is 24,000/mm3

A nurse is caring for a preschooler who expresses the need to leave because their doll is scared to be at home alone. Which of the following characteristics of preoperational though is the child exhibiting? A. Egocentrism B. Centration C. Animism D. Magical thinking

Animism

A nurse is collecting data from an infant during a well-child visit. Which of the following sites should the nurse use when obtaining the infant's heart rate? A. Apical B. Radial C. Carotid D. Femoral

Apical

A nurse is caring for a 3 year old female child who is prescribed an indwelling catheter. Which of the following actions should the nurse take when performing this procedure? A. Place a nonsterile drape under the buttocks B. Use a catheter that is 12 French in size C. Insert the catheter another 10 cm (3.9 in) after urine returns D. Apply 2% lidocaine lubricant into the urethral meatus

Apply 2% lidocaine lubricant into the urethral meatus

A nurse is assisting with the care of an infant who has a myelomeningocele. Which of the following actions should the nurse take? A. Encourage the guardian to cuddle the infant B. Monitor the infant's temperature rectally C. Maintain the infant in a supine position D. Apply a sterile, moist dressing on the sac

Apply a sterile, moist dressing on the sac

A school nurse is caring for a school-aged child who has hemophilia and fell on the playground. The child reports a pain level of 4 on a scale of 0 to 10. Which of the following actions should the nurse take? A. Administer an NSAID B. Perform passive range of motion exercises on the joint C. Administer cryoprecipitate D. Apply an ice pack to the joint

Apply an ice pack to the joint

A nurse is reinforcing discharge teaching with the guardian of an infant following a hypospadias repair. Which of the following instructions should the nurse include? A. Clamp the infant's catheter for 30 minutes each day B. Give the infant a tub bath once per day C. Apply antibacterial ointment to the infant's penis once per day D. Decrease the infant's fluid intake for 3 days

Apply antibacterial ointment to the infant's penis once per day

A nurse is caring for a child who has epistaxis. Which of the following actions should the nurse take? A. Administer aspirin B. Tilt the child's head back and apply pressure C. Instruct the child to lie down and rest D. Apply continuous pressure to lower part of the child's nose

Apply continuous pressure to lower part of the child's nose

A nurse is caring for a child who has epistaxis. Which of the following actions should the nurse take? A. Apply a warm cloth to the bridge of the child's nose B. Tilt the child's head back C. Apply continuous pressure to the child's nose for at least 10 minutes D. Administer aspirin for the child's pain

Apply continuous pressure to the child's nose for at least 10 minutes

A nurse is caring for an adolescent client who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following actions should the nurse take? A. Apply heat to the affected area B. Restrict oral fluids C. Administer meperidine IM D. Give oxygen 2 L/min via nasal cannula

Apply heat to the affected area

A nurse is caring for a child who is in a plaster spica cast. Which of the following actions should the nurse take? A. Use a heat lamp to facilitate drying B. Avoid turning the child until the cast is dry C. Assist the client with crutch walking after the cast is dry D. Apply moleskin to the edges of the cast

Apply moleskin to the edges of the cast

A nurse is reinforcing teaching with the guardian of a child who has conjunctivitis. Which of the following actions should the nurse take when demonstrating the correct procedure for administering ophthalmic drops? A. Place the child's head in a flexed position to instill the ophthalmic drops B. Apply pressure to the child's lacrimal punctum for 1 minute following instillation C. Hold the dropper 5 cm (2 in) above the child's eye to instill the ophthalmic drops D. Wipe the excess medication toward the child's inner canthus with a cotton swab

Apply pressure to the child's lacrimal punctum for 1 minute following instillation

A nurse is preparing to administer ophthalmic drops to a child. Which of the following action should the nurse take? A. Position the child with hs head flexed while administering the medication B. Apply pressure to the lacrimal punctum for 1 min following administration C. Hold the dropper 5 cm (2 in) above the eye to administer the medication D. Wipe the excess medication toward the inner canthus with a cotton swab

Apply pressure to the lacrimal punctum for 1 min following administration

A nurse is applying EMLA cream to a child's hand prior to the insertion of an intravenous catheter. Which of the following interventions should the nurse perform? A. Apply the EMLA cream 60 minutes prior to the procedure B. Cleanse the site with alcohol prior to applying the cream C. Rub the cream into the skin using firm pressure in a circular motion D. Choose another site if the area becomes reddened or blanched

Apply the EMLA cream 60 minutes prior to the procedure

A nurse is preparing to administer the varicella vaccine to an adolescent. Which of the following questions should the nurse ask to determine whether there is a contraindication to administering the vaccine? A. "Do you have an allergy to eggs?" B. "Have you ever had encephalopathy following immunizations?" C. "Are you currently taking corticosteroid medication?" D. "Have you ever had an anaphylactic reaction to yeast?"

Are you currently taking corticosteroid medication?"

A nurse is facilitating a group discussion with preschool teachers about child abuse. Which of the following items of data should the nurse share as a common example of a suggestive finding? A. Bruising of both knees with sutures on a knee B. Arm cast for a spiral fracture of the forearm C. Consistent bedwetting at nap time D. Frequent, vague reports of a stomachache or a headache

Arm cast for a spiral fracture of the forearm

A nurse is coordinating care for an adolescent who requires peritoneal dialysis (PD) to treat an acute kidney injury. Which of the following actions should the nurse take? A. Obtain the adolescent's weight and vital signs once per day at the same time B. Immediately stop the PD infusion if the adolescent reports feeling uncomfortable full C. Ask if the adolescent would like to record the amount of solution infused and drained D. Reinforce teaching with the adolescent by emphasizing the right way to do things

Ask if the adolescent would like to record the amount of solution infused and drained

A nurse is preparing to use the Oucher pain rating scale to determine the pain level of a 3 year old preschooler who is 24 hours postoperative following a tonsillectomy. Which of the following actions should the nurse take? A. Ask the child to choose the cartoon-like face with the expression that best indicates her level of pain B. Ask the child to choose the number from 0 to 10 along a line that best indicates her level of pain C. Ask the child to choose up to 4 large red poker chips to indicate her level of pain D. Ask the child to choose the photograph of a child's face that best indicates her level of pain

Ask the child to choose the photograph of a child's face that best indicates her level of pain

A nurse is collecting data from an 8 year old child who was brought to the clinic by a parent. The parent reports the child has missed school for 3 weeks and refuses to go back due to "not feeling well." Which of the following actions should the nurse take during the initial interview with the child? A. Ask the child to describe what things were like right before wanting to avoid school B. Directly ask the child why going to school is no longer fun C. Tell the child it is okay not to like school, but she has to go back D. Reassure the child that things might not be going well right now, but they will soon improve

Ask the child to describe what things were like right before wanting to avoid school

A nurse is preparing to obtain a blood sample from a 4 year old child. Which of the following interventions should the nurse plan to take? A. Place all supplies needed in the child's room prior to the procedure B. Use a 21 gauge needle for the venipuncture C. Perform a heel lance to reduce the pain of blood sampling D. Ask the child's guardian to restrain the child during the procedure

Ask the child's guardian to restrain the child during the procedure

A nurse is preparing to administer furosemide to a toddler who has a heart defect. Which of the following actions should the nurse take to identify the toddler? A. Ask the child to state their name B. Ask the pharmacy for the child's room number C. Ask the child to state their birthday D. Ask the guardian to verify the child's name

Ask the guardian to verify the child's name

A nurse in an acute pediatric unit is contributing to the plan of care for a preschooler. Which of the following recommendations should the nurse make? A. Request that a laboratory technician obtains blood specimens in the preschooler's room B. Encourage the preschooler to rest quietly for 30 minutes following traumatic procedures C. Use the terminology "quick stick" when preparing to administer an injection D. Ask the parent if she would like to hold the preschooler during an assessment by the respiratory therapist

Ask the parent if she would like to hold the preschooler during an assessment by the respiratory therapist

A nurse is caring for a preschooler who has acute leukemia and methicillin-resistant Staphylococcus aureus (MRSA). The parents are not allowed to take the client to the hospital playroom, and the child appear bored. Which of the following actions should the nurse take? A. Provide the preschooler with some plastic beads and string that can be used at the bedside B. Encourage the parents to bring the preschooler's siblings to visit more frequently C. Ask the parents to bring toys from home for the preschooler D. Remind the parents that the preschooler will be able to play once isolation precautions are no longer required

Ask the parents to bring toys from home for the preschooler

A nurse is caring for a preschooler who has acute leukemia and methicillin-resistant Staphylococcus aureus (MRSA). The parents are not allowed to take the client to the hospital playroom, and the child appears bored. Which of the following actions should the nurse take? A. Provide the preschooler with some plastic beads and string that can be used at the bedside B. Encourage the parents to bring the preschooler's siblings to visit more frequently C. Ask the parents to bring toys from home for the preschooler D. Remind t he parents that the preschooler will be able to play once isolation precautions are no longer required

Ask the parents to bring toys from home for the preschooler

A nurse is collecting data from an adolescent who sustained a broken tibia. Following the application of a fiberglass cast, the adolescent reports pain and a tingling feeling in the limb. Which of the following actions should the nurse take first? A. Give the adolescent ibuprofen B. Elevate the adolescent's leg on pillows C. Place an ice pack on the cast D. Assess for manifestations of circulatory impairment

Assess for manifestations of circulatory impairment

A nurse is called to stand by at a high risk delivery. After several pushes, the mother delivers the infant. Which of the following steps should the nurse take first following the delivery of the newborn? A. Complete Ballard scoring B. Obtain the infant's weight C. Place identification bands on the infant's wrist and ankle D. Assess the infant's heartbeat and breathing

Assess the infant's heartbeat and breathing

A nurse is reinforcing teaching with a group of parents and guardians about child development. Which of the following recommendations should the nurse make to promote the developmental task of industry in a school-aged child? A. Have an after school snack ready for the child each day B. Assign the child several small chores C. Talk with the child about what he/she wants to do when he/she is an adult D. Talk openly about the family's value system

Assign the child several small chores

A nurse is caring for an 8 year old child in the acute care setting. Which of the following actions should the nurse take? A. Reinforce teaching about scheduled procedures several days in advance B. Assign the child the task of checking her blood sugar before meals C. Keep all medical equipment out of sight except when in use D. Apply adhesive bandages after every type of skin puncture

Assign the child the task of checking her blood sugar before meals

A nurse is contributing to the plan of care for a school-aged child with cystic fibrosis who is hospitalized. Which of the following should the nurse plan to include? A. Administer pancreatic enzymes 1 hour before each meal B. Offer the child a cough suppressant as needed C. Assist the child with choosing high protein, high fat foods for meals D. Provide chest physiotherapy once a day before bedtime

Assist the child with choosing high protein, high fat foods for meals

A nurse is caring for a child who has had watery diarrhea for the past 3 days. Which of the following is an action for the nurse to take? A. Offer chicken broth B. Assist with initiating oral rehydration therapy C. Assist with starting an infusion of a hypertonic IV solution D. Keep NPO until the diarrhea subsides

Assist with initiating oral rehydration therapy

A nurse is assisting with the care for a toddler who has a Wilms' tumor. Which of the following actions should the nurse take? A. Palpate the child's abdomen to identify the size of the tumor B. Assist with preparing the child for surgery C. Reinforce teaching with the guardians about dialysis D. Obtain a 24 hr urine specimen from the child

Assist with preparing the child for surgery

A nurse is reinforcing teaching with the parents of an infant who is breastfeeding. When should the nurse instruct the parents to introduce solid foods into the infant's diet? A. After the rooting reflex disappears B. At 2 to 3 months of age C. After the infant's first tooth erupts D. At 4 to 6 months of age

At 4 to 6 months of age

A nurse is assisting a group of guardians of adolescents to develop skills that will improve communication within the family. The nurse hears one guardian state, "My son knows he better do what I say." Which of the following parenting styles is the parent exhibiting? A. Authoritarian B. Permissive C. Authoritative D. Passive

Authoritarian

A nurse is assisting an education program for a group of caregivers of preschooler about promoting optimum nutrition. Which of the following information should the nurse include in the program? A. Saturated fats should equal 20% of total daily caloric intake B. Average calorie intake should be 1,800 calories per day C. Daily intake of fruits and vegetables should total 2 servings D. Healthy diets include a total of 8 g protein each day

Average calorie intake should be 1,800 calories per day

A nurse is caring for a 3 year old toddler who has Haemophilus influenzae type b meningitis. Which of the following actions should the nurse take? A. Monitor the anterior fontanel every 8 hours B. Maintain airborne precautions for 72 hours C. Avoid using a pillow when supine D. Place the bed in the Trendelenburg postion

Avoid using a pillow when supine

A nurse is collecting data from a 6 month old child who is experiencing a sickle cell crisis. Which of the following areas should the nurse observe when monitoring for manifestation of splenic sequestration? A B C

B *splenic sequestration is an enlargement of the spleen due to pooling of sickled cells in the blood. LUQ

A nurse is preparing to administer an intramuscular injection to an 11 month old infant. In which of the following areas should the nurse administer the injection? A B C

B the vastus lateralis muscle

A nurse is collecting data from a toddler who has AIDS. The nurse should identify which of the following findings as an indication of an opportunistic infection? A. Koplik spots B. Peripheral neuropathy C. Chancre D. Candidiasis

Candidiasis

A nurse is collecting data from an infant who has acute gastroenteritis. Which of the following finding should the nurse identify as the priority? A. Decreased skin turgor B. Capillary refill 5 seconds C. Heart rate 150/min D. Dry mucous membranes

Capillary refill 5 seconds

A nurse is discussing the causes of chronic diarrhea with a client. Which of the following conditions is caused by malabsorption? A. Celiac disease B. Ulcerative colitis C. Hirschsprung's disease D. Crohn's disease

Celiac disease

A nurse is using an otoscope to examine a child's ears. Which of the following findings should the nurse expect? A. Light reflex is located at the 2 o-clock position B. Tympanic membrane is red in color C. Bony landmarks are not visible D. Cerumen is present bilaterally

Cerumen is present bilaterally

A nurse is caring for a 7 year old child who is in skeletal traction following a complete fracture of the femur. Which of the the following diversional activities should the nurse offer the child? A. Puzzle with large pieces B. Building blocks C. Finger paints D. Chapter books

Chapter books

A nurse is caring for a toddler in the immediate postoperative period following the placement of a ventriculoperitoneal (VP) shunt. Which of the following interventions should the nurse perform? A. Check for abdominal distention B. Keep the head of the bed elevated 60 to 90 C. Palpate the anterior fontanel for bulging or tenseness D. Position the child to keep pressure on the operative side

Check for abdominal distention

A nurse is assisting with the care of a 2 year old child who has a heart defect and is scheduled for cardiac catherization. Which of the following actions should the nurse take? A. Place on NPO status for 12 hr prior to the procedure B. Check for iodine or shellfish allergies prior to the procedure C. Elevate the affected extremity following the procedure D. Limit fluid intake following the procedure

Check for iodine or shellfish allergies prior to the procedure

A nurse is caring for a child who has been in Buck's traction for 2 days. Which of the following actions should the nurse take to prevent complications? A. Manually move the weights to the floor when the child is experiencing pain B. Check for pulses in the affected leg every 4 hours C. Cleanse the pins every 12 hours D. Ask parents to discourage visitors for the child

Check for pulses in the affected leg every 4 hours

A nurse is planning care for a 3 month old infant who has an ileostomy. Which of the following interventions should the nurse include in the plan? A. Avoid laying the infant on his abdomen B. Avoid tucking the appliance into the infant's diaper C. Check the bag for stool every 4 hours D. Replace the appliance every 3 days

Check the bag for stool every 4 hours

A nurse is caring for a child who has acute glomerulonephritis. Which of the actions should the nurse take? A. Maintain the child on strict bed rest B. Check the child's blood pressure every 4 hours C. Administer albumin to the child every 8 hours D. Provide the child with a low-carbohydrate diet

Check the child's blood pressure every 4 hours

A nurse is reinforcing teaching about post-seizure care with the parent of a school-aged child who has a seizure disorder. Which of the following should the nurse include? A. Position the child supine for 30 minutes following the seizure B. Check the child's oral cavity for the presence of injuries C. Encourage sips of clear fluids during the immediate post-seizure phase D. Expect the child to be difficult to arouse for up to 30 minutes after the seizure

Check the child's oral cavity for the presence of injuries

A nurse is caring for an adolescent who has acne and a new prescription for isotretinoin. Which of the following laboratory findings should the nurse plan to monitor? A. Cholesterol and triglycerides B. BUN and creatinine C. Blood potassium D. Blood sodium

Cholesterol and triglycerides

A nurse is caring for a client who has a superficial partial-thickness burn. Which of the following actions should the nurse take? A. Monitor IV infusion of 0.9% sodium chloride B. Apply cool, wet compresses to the affected area C. Clean the affected area using a soft-bristle brush D. Administer morphine sulfate

Clean the affected area using a soft-bristle brush

A nurse is caring for a toddler who reportedly ingested a poisonous substance. Which of the following interventions should the nurse perform first? A. Inspect the mouth for the presence of the suspected poison B. Identify the poisonous substance C. Collect data on the child's vital signs D. Place the child in a knee-chest position

Collect data on the child's vital signs

A nurse is contributing to the plan of care for a school-aged child who has encopresis. Which of the following interventions should the nurse include in the plan of care? A. Collect data regarding any recent stress factors in the child's environment B. Develop a schedule for the child to attempt bowel movements every 4 hours during the day C. Ensure the use of stool softeners is discontinued after 5 days D. Withhold privileges on days that bowl accidents occur

Collect data regarding any recent stress factors in the child's environment

A nurse is assisting with the admission orders for a female adolescent who has anorexia nervosa. The nurse should identify that which of the following laboratory tests is the priority to obtain? A. Albumin B. Complete metabolic panel (CMP) C. Human chorionic gonadotropin (hCG) D. Cholesterol

Complete metabolic panel (CMP)

A nurse is preparing to administer an enteral feeding to a child who has cerebral palsy and a nasogastric tube. Which of the following actions should the nurse take? A. Administer 20 mL/min formula by gravity B. Refrigerate the formula for 30 min prior to administration C. Confirm that the pH of the stomach contents is 5 or less D. Flush the tube with 5 to 15 mL of 0.9% sodium chloride

Confirm that the pH of the stomach contents is 5 or less

A nurse is reinforcing discharge teaching with the guardian of an adolescent who is postoperative following a tonsillectomy. Which of the following manifestations should the guardian report to the provider? A. Nasal secretions containing dark brown blood B. Constant clearing of the throat C. Unpleasant odor from the oral cavity D. Temperature of 37.7 C (99.8 F) at 48 hours postoperatively

Constant clearing of the throat

A nurse is collecting data from an infant who has untreated congenital hypothyroidism. Which of the following medications should the nurse expect? A. Constipation B. Hyperreflexia C. Oily skin D. Hyperthermia

Constipation

A nurse is reinforcing dietary teaching with the parent of a toddler who has phenylketonuria. Which of the following foods should the nurse recommend? A. Whole milk B. Ground beef C. Cooked carrots D. Eggs

Cooked carrots

A nurse is reinforcing teaching with the parent of a school-aged child who has celiac disease. Which of the following foods selected by the parent indicates an understanding of the teaching? A. Corn tortilla with black beans B. Pizza C. Canned soup D. Hot dogs

Corn tortilla with black beans

A nurse is collecting the vital signs of a 1-month-old infant. Which of the following actions should the nurse perform? A. Use of a cuff to ascultate blood pressure B. Determine heart rate by taking radial pulse C. Count respirations before taking other vital signs D. Measure temperature by placing the thermometer in the infant's ear

Count respirations before taking other vital signs

A nurse is assisting with the care of a 6 month old infant who has respiratory insufficiency and requires continuous pulse oximetry monitoring. Which of the following actions should the nurse take? A. Reposition the infant's oximetry sensor once every 24 hours B. Secure the oximetry sensor to the infant's wrist C. Apply conduction gel to the infant's skin 10 minutes before attaching the oximetry sensor D. Cover the infant's oximetry sensor with clothing

Cover the infant's oximetry sensor with clothing

A nurse is contributing to the plan of care for a 6 month old infant who is scheduled to have continuous pulse oximetry monitoring. Which of the following interventions should the nurse recommend including? A. Reposition the sensor to a new site once every 24 hours B. Secure the oximetry sensor to the infant's wrist C. Apply conduction gel to the infant's skin before attaching the sensor D. Cover the oximetry sensor with clothing

Cover the oximetry sensor with clothing

A nurse is caring for a toddler. Which of the following laboratory findings should the nurse report to the provider? A. BUN 8 mg/dL B. Uric acid 3.0 mg/dL C. Creatinine 0.9 mg/dL D. Urine specific gravity 1.010

Creatinine 0.9 mg/dL *0.3-0.7 is reference range for toddler

A nurse is preparing to administer iron dextran IM to a school-age child who has iron deficiency anemia. Which of the following actions by the nurse is appropriate? A. Administer the dose in the deltoid muscle B. Use the Z-track method when administering the dose C. Avoid injecting more than 2 mL with each dose D. Massage the injection site for 1 min after administering the dose

Use the Z-track method when administering the dose

A nurse is caring for a child who has a vesicular rash for 6 days. The parents of the child ask the nurse what illness caused this rash. The nurse should explain the child has which of the following conditions? A. Measles B. Fifth disease C. Tetanus D. Varicella

Varicella

A nurse is preparing to administer an intramuscular injection to a 2 month old infant. In which of the following sites should the nurse plan to administer the injection? A. Vastus lateralis B. Dorsogluteal C. Deltoid D. Abdomen 5 cm (2 in) from the umbilicus

Vastus lateralis

A nurse is reinforcing teaching with the parent of a school-age child who has lactose intolerance. Which of the following supplements should the nurse instruct the patient to include in the child's diet? A. Zinc B. Vitamin D C. Thiamine D. Folic acid

Vitamin D

A nurse is reinforcing education with a group of parents about toddler language development during a well-child visit. Which of the following findings should the parent expect in an 18 month old toddler? A. Ability to refer to self by name B. Vocabulary of 10 or more words C. Ability to follow simple directional commands D. Ability to name a color

Vocabulary of 10 or more words

A nurse in an urgent care clinic is collecting data from an infant who recently started taking digoxin for a supraventricular arrhythmia. Which of the following findings should the nurse identify as a possible indication of digoxin toxicity? A. Irritability B. Diaphoresis C. Vomiting D. Tachycardia

Vomiting

A nurse is reviewing the laboratory reports of a child with acute nephrotic syndrome who has been receiving prednisone by mouth for the past week. Which of the following findings should the nurse report to the provider? A. Serum sodium 142 mEq/L B. Serum potassium 4 mEq/L C. WBC count 3,000/mm3 D. Platelet count 298,000/mm3

WBC count 3,000/mm3

A nurse is reinforcing discharge teaching with the guardians of a 6 month old infant following a surgical procedure to repair a hypospadias. Which of the following instructions should the nurse include? A. Wait 1 week before giving the infant a tub bath B. Apply antifungal ointment to the infant's penis C. Avoid giving the infant fruit juice D. Apply dry gauze dressing to the infant's penis twice daily

Wait 1 week before giving the infant a tub bath

A nurse in a pediatric clinic is preparing to assist with a sweat chloride test for a toddler who is suspected to have cystic fibrosis. Which of the following actions should the nurse plan to take? A. Verify the toddler has been NPO for 6 hours prior to the test B. Document the toddler's food intake for the past 72 hours C. Warm the temperature of the toddler's examination room D. Expose the toddler's back for the application of electrodes

Warm the temperature of the toddler's examination room

A nurse is contributing to the plan of care for a toddler who has acute renal failure. Which of the following interventions should the nurse include in the plan? A. Provide a high-protein, low-carbohydrate diet B. Administer potassium supplements C. Weigh the child each day at the same time D. Rapidly infuse prescribed intravenous fluids

Weigh the child each day at the same time

A nurse is caring for a child who has glomerulonephritis. Which of the following actions should the nurse take? A. Monitor the child's blood pressure twice per day B. Maintain the child on bed rest for 3 days C. Weigh the child once each day D. Increase the child's daily intake of sodium

Weigh the child once each day

A school nurse is checking the lunch tray of a school-aged child who has a new diagnosis of celiac disease. Which of the following foods should the nurse instruct the child remove from the tray? A. Creamed corn B. White rice C. Baked potato D. Wheat roll

Wheat roll

A nurse is reinforcing teaching with the parent of an infant who has heart failure and a new prescription for digoxin elixir. Which of the following pieces of information should the nurse include? A. Withhold the medication if the infant's heart rate is less than 110/min B. Mix the medication in 120 mL (4 oz) of infant formula C. Expect the infant to vomit frequently while taking this medication D. Double the dose if the infant has increased edema

Withhold the medication if the infant's heart rate is less than 110/min

A nurse is reinforcing teaching with the family of an adolescent client who was recently diagnosed with celiac disease. Which of the following foods should the nurse recommend? A. Graham crackers B. Rye bread C. Whole wheat spaghetti D. Yellow corn

Yellow corn

A nurse is reinforcing teaching with the parents of a child who has cystic fibrosis and is taking pancrelipase as a pancreatic enzyme replacement. The nurse should plan to inform the child's parents that the therapeutic effects of this medication can be evaluated by which of the following? A. Blood glucose levels B. amount and consistency of stools C. chloride sweat tests D. BUN and creatinine clearance tests

amount and consistency of stools

A nurse is reinforcing dietary teaching about a low-sodium diet with the parents of a child who is recovering from acute glomerulonephritis. Which of the following food choices by the parents indicates an understanding of the teaching? A. pretzels B. apples C. canned corn D. peanut butter

apples

A nurse is collecting data from a 12 month old infant during a well-child visit. The nurse should identify which of the following findings as a deviation from expected growth and development? A. vocabulary of three words B. negative Babinski reflex C. birth weight doubled D. unable to build a two-block tower

birth weight doubled

A nurse is caring for a child who has electrical burns on her lower arms and hands. Which of the following findings indicates the child is experiencing a complication of the injury? A. Dark urine B. 2+ radial pulses C. Respiratory rate of 20/min D. Minimal pain

Dark urine

A nurse is collecting data from a toddler who has gastroenteritis. Which of the following findings indicates the toddler is experiencing severe dehydration? A. Slight thirst B. Capillary refill of 3 seconds C. Deep, rapid respirations D. Decreased tear production

Deep, rapid respirations

A nurse is reinforcing teaching with the guardian of a school-aged child who has diabetes mellitus about how to recognize diabetic ketoacidosis (DKA). Which of the following findings should the nurse describe as a manifestation of this complication? A. Slow heart rate B. Protruding eyeballs C. Deep, rapid respirations D. Decreased urinary output

Deep, rapid respirations

A nurse on a pediatric unit is assisting the manager with preparing an education program on working with families for a group of newly hired nurses. Which of the following should the nurse include when discussing the developmental theory? A. Describes that stress is inevitable B. Emphasizes that change with one member affects the entire family C. Provides guidance to assist families adapting to stress D. Defines consistencies in how families change

Defines consistencies in how families change

A nurse is collecting data from a child who has chronic kidney disease. Which of the following findings should the nurse expect? A. Flushed face B. Hyperactivity C. Weight gain D. Delayed growth

Delayed growth

A nurse is caring for a 6-year old child who is experiencing encopresis. Which of the following actions should the nurse take? A. Instruct the child's guardian to limit stool softener use to no more than twice per week B. Encourage the child to attempt to have a bowel movement 4 times per day C. Determine if there are any recent stressors in the child's environment D. Urge the child's guardian to provide negative consequences when the child has a bowel accident

Determine if there are any recent stressors in the child's environment

A nurse is contributing to the plan of care for a toddler who has cerebral palsy. Which of the following interventions should the nurse include? A. Structure interventions according to the toddler's chronological age. B. Determine the toddler's need for an evaluation of hearing ability C. Monitor the toddler's pain level routinely using a numeric rating scale D. Provide total care for daily hygiene activities

Determine the toddler's need for an evaluation of hearing ability

A nurse is planning to reinforce education with the parents of a school-aged child who has attention-deficit/hyperactivity disorder (ADHD). Which of the following instructions should the nurse include? A. Develop a daily morning task chart for child B. Request their child to be seated near the back of the classroom C. Adjust the child's schedule so that academic courses are in the afternoon D. Offer choices as frequently as possible

Develop a daily morning task chart for child

A nurse is collecting data about a 4 year old client's cognitive development during a well-child visit. Which of the following should the nurse expect the child to display? A. Conservation B. Development of the superego C. Concrete operational thought D. Separation anxiety

Development of the superego

A nurse at a clinic is preparing to administer highlight immunizations to a 5 year old child. Which of the following immunizations should the nurse plan to give? A. Diptheria, tetanus, and pertussis (DTaP) B. Pneumococcal (PCV) C. Haemophilus influenza type B (Hib) D. Hepatitis B (Hep B)

Diptheria, tetanus, and pertussis (DTaP)

A nurse is preparing to administer an intramuscular (IM injection to a child. Which of the following muscle groups is contraindicated? A. Deltoid B. Ventrogluteal C. Vastus lateralis D. Dorsogluteal

Dorsogluteal

A nurse is contributing to the plan of care for a hospitalized school-aged child who has measles. Which of the following activities should the nurse recommend? A. Drawing a picture with colored pencils B. Watching television in the unit playroom C. Socializing with other children in the hallway D. Putting together a puzzle with large pieces

Drawing a picture with colored pencils

A nurse is assisting with the plan of care for a child who has meningococcal meningitis. Which of the following isolation precautions should the nurse plan to implement? A. Airborne precautions B. Contact precautions C. Protective environment D. Droplet precautions

Droplet precautions

A nurse is checking the motor development of a 9 month old infant. Which of the following findings should the nurse report to the provider as a possible development delay? A. Grasping a small object with just the thumb and index finger B. Dropping a cube when passing it between the hands C. Sitting from a standing position by falling down D. Losing balance when leaning sideways while sitting down

Dropping a cube when passing it between the hands

A nurse is reinforcing teaching with the parent of a school-aged child who has pediculosis. Which of the following instructions should the nurse include? A. Machine wash clothing in cold water B. Dry clothing in a hot dryer for at least 20 minutes C. Soak combs and brushes for 5 min in boiling water D. Seal non-washable items in a bag for 7 days

Dry clothing in a hot dryer for at least 20 minutes

A nurse is caring for an infant who is 6 months old and has moderate dehydration. Which of the following findings should the nurse expect? A. Absent tears B. Weight loss >10% C. Lethargy D. Dry mucous membranes

Dry mucous membranes

A nurse is caring for a school-aged child who begins to have a tonic-clonic seizure when leaving the bathroom. Which of the following actions should the nurse take first? A. Obtain a portable suction machine and suction tubing B. Ease the child to the floor in Sims' position C. Time the length of the seizure D. Notify the child's parents

Ease the child to the floor in Sims' position

A nurse is assisting with the care of a 3-month-old infant who is postoperative following a cleft lip and palate repair. Which of the following items should the nurse use to protect the surgical site? A. Clove-hitch limb restraints B. Jacket restraint C. Mummy restraint D. Elbow restraints

Elbow restraints

A nurse is collecting data on an infant who has coarctation of the aorta. Which of the following findings should the nurse expect? A. Clubbing of the fingernails B. Hypercyanotic spells C. Elevated blood pressure in the arms D. Cyanosis at rest

Elevated blood pressure in the arms

A nurse is providing immediate postoperative care for a child who had a tonsillectomy. Which of the following actions should the nurse take? A. Offer ice cream or pudding when the child is fully awake B. Eliminate the use of a straw when offering fluids C. Apply a heating pad to the neck area D. Instruct the child to blow his nose to clear bloody secretions

Eliminate the use of a straw when offering fluids

A nurse is caring for a child who has enuresis. The nurse should identify that which of the following conditions is a complication of enuresis? A. urinary tract infections B. Emotional problems C. Urosepsis D. Progressive kidney disease

Emotional problems

A nurse is contributing to the plan of care for a child who has type 1 diabetes mellitus and is experiencing an acute illness. Which of the following actions should the nurse include in the plan of care? A. Monitor blood glucose levels every 6 hr B. Withhold insulin until the illness has passed C. Encourage an increased fluid intake D. Administer glucagon every 3 hr

Encourage an increased fluid intake

A nurse is contributing to the plan of care for a child who has a urinary tract infection. Which of the following interventions should the nurse include? A. Administer an antidiuretic B. Restrict fluids C. Evaluate the child's self-esteem D. Encourage frequent voiding

Encourage frequent voiding

A nurse is caring for a toddler who has asthma. The parents are concerned about the toddler's reaction to the hospitalization. Which of the following actions should the nurse take to decrease the child's anxiety? A. Provide privacy B. Give the child a thorough explanation before providing care C. Encourage rooming-in D. Tell the child this hospitalization will help fix her

Encourage rooming-in

A nurse is reinforcing teaching about home care with the guardian of an adolescent who has hemophilia. Which of the following pieces of information should the nurse provide? A. Encourage the adolescent to participate in non-contact sports B. Provide the adolescent with a firm-bristled toothbrush C. Administer aspirin to the adolescent for episodes of pain D. Provide disposable razors to the adolescent for shaving

Encourage the adolescent to participate in non-contact sports

A nurse is planning to use guided imagery for an early school-aged child who continues to have mild discomfort following the administration of an analgesic. Which of the following techniques should the nurse plan to use? A. Give the child a kaleidoscope and ask the child to find different designs B. Encourage the child to take a deep breath and let the body go limp on the exhale C. Teach the child to picture a stop sign whenever the pain begins D. Encourage the child to focus on a recent pleasurable experience

Encourage the child to focus on a recent pleasurable experience

A nurse is planning care for a school-aged child who has juvenile idiopathic arthritis (JIA). Which of the following actions should the nurse include in the plan? A. Encourage the child to sleep for 1 hour each afternoon B. Apply cold compressess to the child's affected joints each morning C. Encourage the child to participate in physical activities D. Limit the child's intake of foods that are high in uric acid

Encourage the child to participate in physical activities

A nurse is caring for a newborn who has spina bifida. The newborn's parents are upset by the diagnosis. Which of the following actions should the nurse take? A. Discuss placement options for the newborn B. Encourage the parents to touch and care for the newborn C. Reassure the parents that everything will be fine D. Avoid talking about the newborn's defect until the parents bring up the subject

Encourage the parents to touch and care for the newborn

A nurse is collecting data from a child who has stage 1 Hodgkin disease. Which of the following findings should the nurse expect? A. Generalized petechiae B. Enlarged lymph nodes C. Chronic vomiting D. Dependent edema

Enlarged lymph nodes

A nurse caring for a child who is receiving oxygen therapy and is on a continuous oxygen saturation monitor that is reading 89%. Which of the following actions should the nurse take first? A. Increase the oxygen flow rate B. Encourage the child to take deep breaths C. Ensure proper placement of the sensor probe D. Place the child in the Fowler's position

Ensure proper placement of the sensor probe

A nurse is assisting with the admission of a 12 year old child who is blind and is scheduled to have open reduction internal fixation of the right arm. Which of the following actions should the nurse take? A. Touch the child before speaking to avoid startling her B. Remind the child not to touch tubing and dressings that are in place C. Assign an assistive personnel (AP) to feed the child at each meal D. Explain the different sounds that can be heard from the child's bedside

Explain the different sounds that can be heard from the child's bedside

A nurse is reinforcing preoperative teaching for a 5-year-old child. Which of the following interventions should the nurse include? A. Explain the long-term benefits of the procedure B. Provide the child with diagrams and pictures while explaining the procedure C. Use correct medical terminology during the teaching session D. Explain the procedure in terms of what the child will feel, see, hear, and taste

Explain the procedure in terms of what the child will feel, see, hear, and taste

A nurse is caring for an infant who has a hydrocele. Which of the following actions should the nurse take? A. Prepare the infant for surgery B. Explain to the guardians that the issue generally self-resolves C. Retract the foreskin and cleanse several times daily D. Refer the family for genetic counseling

Explain to the guardians that the issue generally self-resolves

A nurse is assessing the pain level of a 3 year old child who is postoperative following abdominal surgery. Which of the following pain scales should the nurse use? A. Word-graphic rating scale B. Color tool C. FACES pain rating scale D. Numeric scale

FACES pain rating scale

A nurse is collecting data from an 18 month old child who is postoperative. Which of the following pain scales should the nurse use? A. FACES B. CRIES C. FLACC D. PIPP

FLACC

A nurse is collecting data from an infant about pain. Which of the following pain scales should the nurse use? A. FACES B. FLACC C. Oucher D. Numeric scale

FLACC

A nurse is collecting data on the postoperative pain level of a 2 year old child. Which of the following methods should the nurse use? A. FLACC pain assessment B. Numeric scale C. Word Graphic Rating Scale D. FACES Pain Rating Scale

FLACC pain assessment

A nurse is collecting data from a 2 year old toddler at a well child visit. Which of the following findings should the nurse report to the provider? A. Displays occasional temper tantrums B. Speaks using 2-3 word phrases C. Plays alongside but not with other children D. Falls down when throwing a ball overhead

Falls down when throwing a ball overhead

A nurse is collecting development data from a 4 year old child. The nurse should expect the child to be able to perform which of the following activities? A. Fasten buttons on a shirt B. Tie shoe laces C. Part and comb hair D. Cut meat at dinner

Fasten buttons on a shirt

A nurse is reinforcing teaching with a guardian whose child was exposed to poison ivy. Which of the following instructions should the nurse provide? A. Flush the child's skin within 15 min with cold, running water B. Apply miconazole topical ointment to the area daily for 1 week C. Wash the child's clothes in cool, detergent free water D. Encourage the guardian to keep the child away from other children for a week

Flush the child's skin within 15 min with cold, running water

A nurse is reinforcing education with the parent of a toddler who has phenylketonuria and is prescribed a restricted-phenylalanine diet. Which of the following foods would be an appropriate choice for this child? A. Peanut butter sandwich B. Scrambled eggs C. French fries D. Slice of cheddar cheese

French fries

A nurse is collecting data from a child who is postoperative following a tonsillectomy. Which of the following is a clinical finding of postoperative bleeding? A. Hgb 11.6 and Hct 37% B. Inflamed and reddened throat C. Frequent swallowing and clearing of the throat D. Blood-tinged mucus

Frequent swallowing and clearing of the throat

A nurse is reinforcing teaching to the guardian of a toddler who is receiving chemotherapy and has developed stomatitis. Which of the following instructions should the nurse include in the teaching? A. Administer viscous lidocaine before feedings B. Brush teeth using a firm toothbrush C. Frequently rinse the mouth with chlorhexidine mouthwash D. Increase vitamin C intake by offering orange juices

Frequently rinse the mouth with chlorhexidine mouthwash

A nurse working on a maternal-newborn unit is assisting with planning an in-service training session for staff about assisting new mothers with breastfeeding. Which of the following infant conditions should the nurse recommend including in the teaching as a contraindication for breastfeeding? A. Galactosemia B. Hyperbilirubinemia C. Glycogen storage disease D. Hypothyroidism

Galactosemia

A nurse is reviewing the medical record of a newborn who has necrotizing enterocolitis (NEC). The nurse should identify that which of the following findings is a risk factor for NEC? a. Macrosomia b. Transient tachypnea of the newborn (TTN) c. Maternal gestational hypertension d. Gestational age 36 weeks

Gestational age 36 weeks

A nurse is caring for a 1 week old newborn whose mother wants to breastfeed. For which of the following diagnoses is breastfeeding contraindicated due to the newborn's inability to process lactose A. Galactosemia B. Jaundice C. Phyenlyketonuria D. Hypothyroidism

Glactosemia

A nurse is caring for a child who has type 1 diabetes mellitus and has been receiving insulin via subcutaneous infusion pump. Which of the following laboratory tests would verify the average blood glucose level over the past 2 months? A. Postprandial blood glucose B. Fasting blood glucose C. Glycosylated hemoglobin D. Mean corpuscular hemoglobin

Glycosylated hemoglobin

A nurse is participating in a discussion about prepubescence and preadolescence with a group of guardians of school-age children. Which of he following information should the nurse include in the discussion? A. Initial physiologic changes appear during early childhood B. Changes in height and weight occur slowly during this period C. Growth differences between boys and girls become evident D. Sexual maturation becomes highly visible in boys

Growth differences between boys and girls become evident

A nurse is assisting with the care of a child who has tonic-clonic seizures. Which of the following actions should the nurse take? A. Ensure the availability of soft extremity restraints B. Place a padded tongue blade at the bedside C. Have a suction canister and tubing available in the room D. Keep the child's bed in the highest position

Have a suction canister and tubing available in the room

A nurse is assisting with performing a peripheral vision test on a child. Which of the following actions should the nurse take? A. Place the child 10 feet away from a Snellen chart B. Show a set of cards to the child one at a time C. Cover the child's eye while performing the test on the other eye D. Have the child focus on an object while performing the test

Have the child focus on an object while performing the test

A nurse is preparing to obtain a peak expiratory flow rate from an adolescent. Which of the following actions should the nurse take? A. Document the average of the client's three attempts B. Instruct the client to exhale slowly over 5 seconds into the meter C. Determine the zone according to the client's age D. Have the client stand during the procedure

Have the client stand during the procedure

A nurse is collecting data from a 2 1/2 year old toddler at a well child visit. Which of the following findings should the nurse report to the provider? A. Height increased by 7.5 cm (3 in) in the past year B. Head circumference exceeds chest circumference C. Anterior and posterior fontanels are closed D. Current weight equals four times the birth weight

Head circumference exceeds chest circumference

A nurse is collecting data on a 6 month old infant. Which of the following findings should the nurse identify as unexpected and report to the provider? A. Head lag when pulled to a sitting position B. Weight that has doubled since birth C. Absence of a pincer grasp D. Respiratory rate 30/min

Head lag when pulled to a sitting position

A nurse in a provider's office is collecting data from a client. The nurse determines the client's body mass index (BMI) is 21.2. This finding is classified as which of the following? A. Underweight B. Healthy weight C. Overweight D. Obese

Healthy weight

A nurse is caring for a school-aged child who has acute poststreptococcal glomerulonephritis. Which of the following manifestations should the nurse expect? A. Hypotension B. Elevated serum lipid levels C. Decreased serum potassium levels D. Hematuria

Hematuria

A nurse is caring for an infant whose screening test reveals a potential diagnosis of sickle cell disease. Which of the following tests should be performed to distinguish if the infant has the trait or the disease? A. Sickle solubility test B. Hemoglobin electrophoresis C. Complete blood count D. Transcranial Doppler

Hemoglobin electrophoresis

A nurse is caring for an adolescent client who is experiencing sickle cell crisis. Which of the following laboratory values should the nurse report to the provider? A. total bilirubin 0.5 mg/dL B. reticulocyte count 1% C. WBC count 8,000/mm3 D. Hgb 6 g/dL

Hgb 6 g/dL

A nurse is reviewing the laboratory values of a school-age child who has iron deficiency anemia. Which of the following findings should the nurse expect? A. Hgb 9 g/dL B. Hct 37% C. Iron 100 mcg/dL D. Total iron binding capacity 325 mcg/dL

Hgb 9 g/dL

A nurse is collecting data from a 4 month old infant who has meningitis. Which of the following manifestations should the nurse expect? A. Depressed anterior fontanel B. Constipation C. Presence of the rooting reflex D. High-pitched cry

High-pitched cry

A nurse is collecting data from an infant who is at risk for increased intracranial pressure (ICP). Which of the following findings should indicate to the nurse that this complication is developing? A. High-pitched cry B. Sunken fontanel C. Tachycardia D. Increased awake time

High-pitched cry

A nurse is assisting with the development of a health education program for the parents of school-aged females. Which of the following pieces of information regarding sexual maturation should the nurse include? A. Higher body fat content is associated with earlier onset of menarche B. Pubic hair is typically present prior to breast development C. Ovulation begins after sexual maturation is complete D. Menarche signals the beginning of puberty

Higher body fat content is associated with earlier onset of menarche

A nurse is reinforcing teaching with an adolescent who was recently diagnosed with type 1 diabetes mellitus. Which of the following insulin injection sites should the nurse recommend that the client use during basketball competitions? A. Hip B. Upper arm C. Thigh D. Lower leg

Hip

A nurse is preparing to administer an enema to a 10 month old infant. Which of the following actions should the nurse plan to take? A. Administer the enema using room-temperature tap water B. Insert the tubing 75 cm (3 in) into the rectum C. Position the infant sitting upright on a bedpan while administering the enema D. Hold the infant's buttocks together after administration of the fluid

Hold the infant's buttocks together after administration of the fluid

A nurse is collecting data from a 4 year old preschooler about his gross motor skills. The nurse should expect the preschooler to perform which of the following activites? A. Hopping on 1 foot B. Skipping on alternate feet C. Jumping rope D. Roller skating

Hopping on 1 foot

A nurse is collecting data from a 12 year old child during a well-child checkup. Which of the following physical findings should the nurse report to the provider? A. 5 cm (2 in) of growth in the past year B. Hyperopia C. Presence of pubic hair D. Weight gain of 3 kg (6.6 lb) in the last year

Hyperopia

A nurse is collecting data from a child who has bilateral pheochromocytoma. Which of the following findings should the nurse expect? A. Hypertension B. Abdominal obesity C. Bradycardia D. Loose stools

Hypertension

A nurse is reinforcing teaching with a parent about pinworm testing. At which of the following times should the nurse advise the parent to perform the tape test? A. Immediately after the child has a bowel movement B. After being on a clear liquid diet for 24 hours C. Immediately after the child wakes up in the morning D. After soaking for 20 minutes in a warm bath

Immediately after the child wakes up in the morning

A nurse is collecting data from a 24 month old toddler who has a new diagnosis of autism spectrum disorder (ASD). Which of the following findings should the nurse expect? A. Wanting to be held frequently B. Ability to build a tower of 10 cubes C. Impaired language skills D. Ability to stand on 1 foot

Impaired language skills

A nurse is contributing to the plan of care for a 6 month old infant who has respiratory syncytial virus (RSV). Which of the following interventions should the nurse plan to include? A. Thicken feeding with 5 mL of rice cereal per 30 mL of formula B. Implement droplet and contact precautions C. Administer bronchodilator therapy via blow-by technique D. Use a cool mist vaporizer

Implement droplet and contact precautions

A nurse is caring for a child who has cystic fibrosis and a pulmonary infection. Which of the following findings is the nurse's priority? A. Blood streaking of the sputum B. Dry mucous membranes C. Constipation D. Inability to clear secretions

Inability to clear secretions

A nurse is preparing to administer routine immunizations to a 6 year old child. In addition to the diphtheria, tetanus, and pertussis (DTaP) vaccine; the measles, mumps, and rubella (MMR) vaccine, and the varicella vaccine, which of the following immunizations should the nurse plan to administer? A. Inactivated poliovirus vaccine (IPV) B. Haemophilus influenza type B vaccine (Hib) C. Pneumococcal conjugate vaccine (PCV) D. Hepatitis B vaccine (HBV)

Inactivated poliovirus vaccine (IPV)

A nurse is caring for a 4 year old child who has pneumonia. The child's mother left 2 hr ago, and he is currently experiencing the despair stage of separation anxiety. Which of the following findings should the nurse expect? A. Crying and screaming B. Inactivity and thumb-sucking C. Showing interest in toys D. Attempting to escape and find the parent

Inactivity and thumb-sucking

A nurse is collecting data from an infant who has diabetes insipidus (DI). Which of the following findings should the nurse expect? A. Increased intake of milk B. Decreased serum sodium C. Increased urine output D. Elevated urine specific gravity

Increased urine output

A nurse is collecting data during a well-child assessement of a 7 year old child who takes great pride in bringing school papers home. This behavior demonstrates which of the following of Erikson's stages of psychosocial development? A. Initiative vs. guilt B. Industry vs inferiority C. Identity vs. role confusion D. Autonomy vs. shame and doube

Industry vs. inferiority

A nurse is planning to reinforce teaching for a 9 year old child who has a new diagnosis of diabetes mellitus. The nurse should identify that school-aged children are attempting to master which of the following developmental tasks? A. Initiative vs guilt B. Industry vs. inferiority C. Trust vs. mistrust D. Identity vs role confusion

Industry vs. inferiority

A nurse is contributing to the plan of care for an adolescent client who has human immunodeficiency virus (HIV). Based on the adolescent's diagnosis, which of the following actions should be included in the plan of care? A. Instruct visitors to wear gowns and masks when entering the client's room B. Contact the dietary department to request that foods be delivered on disposable dishes C. Prepare a negative-pressure airflow room for the client D. Inform the client regarding routes of transmission

Inform the client regarding routes of transmission

A nurse is caring for a client who has a moderate burn. Which of the following actions should the nurse take? A. Maintain immobilization of the affected area B. Expose affected area to the air C. Initiate a high-protein, high-calorie diet D. Implement contact isolation

Initiate a high-protein, high-calorie diet

A nurse is contributing to the plan of care for a child who has aplastic anemia. Which of the following interventions should the nurse suggest? A. Initiate protective environment isolation for the child B. Apply pressure for 1 to min at the puncture site following blood specimen collection C. Mix the child's ferrous sulfate elixir twice per day into a glass of milk for administration D. Evaluate the child's blood glucose level every 4 hr

Initiate protective environment isolation for the child

A nurse is planning care for a preschooler who is scheduled for a surgical procedure. The nurse should identify that the preschooler is in which of the following of Erikson's pyschosocial stages of development? A. Industry vs inferiority B. Trust vs. mistrust C. Initiative vs. guilt D. Identity vs. role confusion

Initiative vs. guilt

A nurse is obtaining a temperature reading from an 18 month old infant. Which of the following methods should then nurse use? A. Pull the pinna upward and insert the tympanic thermometer probe into the ear canal B. Insert the lubricated tip of the thermometer 2.5 cm (1 in) into the toddler's rectum C. Obtain an axillary temperature and add 1 C (1.8 F) to the reading D. Place the tip of the thermometer in the left or right posterior sublingual pocket

Insert the lubricated tip of the thermometer 2.5 cm (1 in) into the toddler's rectum

A nurse is reinforcing teaching with the guardian of a school-age child who has acute bacterial conjunctivitis and a new prescription for sulfacetamide. Which of the following instructions should the nurse include? A. Remove dried drainage with a cold washcloth B. Instill medication immediately after cleansing the eye C. Apply an occlusive gauze over the child's eye D. Cleanse the eye by wiping gently from the outer aspect of the eye inward toward the nose

Instill medication immediately after cleansing the eye

A nurse is reinforcing teaching with the guardian of a child about bicycle safety. Which of the following pieces of information should the nurse include? A. Instruct the child to ride against the flow of traffic B. Instruct the child to walk the bike through intersections C. Provide a larger bike that the child will be able to grow into D. Ensure the child's helmet covers the ears

Instruct the child to walk the bike through intersections

A nurse is caring for a toddler who is hospitalized. Which of the following interventions should the nurse take? A. Ask the toddler to state her name prior to administering medication B. Secure a safety net to the moveable crib sides C. Brighten the child's room with latex balloon decorations D. Instruct visitors to notify the healthcare team before leaving the child's room

Instruct visitors to notify the healthcare team before leaving the child's room

A nurse is caring for a toddler who is hospitalized. Which of the following interventions should the nurse take? A. Ask the toddler to state her name prior to administering the medication B. Secure a safety net to the moveable crib sides C. Brighten the child's room with latex balloon decorations D. Instruct visitors to notify the healthcare team before leaving the room

Instruct visitors to notify the healthcare team before leaving the room

A nurse is collecting data from a toddler who has a history of asthma. Which of the following findings should the nurse expect to report to the provider? A. Inspiration phase that is longer than the expiration phase B. Intercostal retractions C. Vesicular breath sounds upon auscultation D. Rise and fall of the abdomen during respirations

Intercostal retractions

A nurse is collecting data from a 2 month old infant. Which of the following findings should the nurse report to the provider? A. Heart rate 140/min B. Respiratory rate 38/min C. Flat anterior fontanel D. Inward eye movements

Inward eye movements

A nurse is reinforcing teaching about when introducing new foods to the guardians of a 4 month old infant. The nurse should recommend that the caregiver introduce which of the following foods first? A. Strained yellow vegetables B. Iron fortified cereals C. Pureed fruits D. Whole milk

Iron fortified cereals

A nurse is assisting with providing education about age appropriate activities for the caregivers of a 6 year old child. Which of the following activities should the nurse include in teaching? A. Jumping rope B. Playing table games C. Solving jigsaw puzzles D. Joining competitive sports

Jumping rope

A nurse is reinforcing discharge teaching with the parents of a school-aged child who has nephrotic syndrome and a prescription for corticosteroid therapy. Which of the following home-care instructions should the nurse include? A. Restrict the child's potassium intake B. Keep the child away from people who have an infection C. Weigh the child once per week using the same scale D. Administer acetaminophen to the child daily

Keep the child away from people who have an infection

A nurse is caring for a 1 week old infant who has manifestations of neonatal abstinence syndrome (NAS). Which of the following actions should the nurse take? A. Keep the infant in a small isolation nursery B. Cover the infant with a loosely draped blanket C. Provide auditory and visual stimulation when the infant is awake D. Minimize the use of a pacifier between the infant's feedings

Keep the infant in a small isolation nursery

A nurse is reinforcing teaching with a group of caregivers about separation anxiety. Which of the following information should the nurse include? A. It is often observed in the school-age child B. Detachment is the stage exhibited in the hospital C. It results in prolonged issues of adaptability D. Kicking a stranger is an example

Kicking a stranger is an example

A nurse is caring for a 3 year old child who has a cyanotic cardiac defect. The child cries when her parents leave the room, worsening her cyanosis and dyspnea. Into which of the following positions should the nurse place the child to reduce these manifestations? A. Orthopneic B. Knee-chest C. Sims' D. Semi-Fowler's

Knee-chest

The clinic nurse is collecting data from a 6 week old infant whose guardian states, "I'm concerned about my baby's hearing." Which of the following manifestations should the nurse report to the provider? A. Absent babbling B. Failure to localize the source of a sound C. Marked inattentiveness D. Lack of startle reflex to a loud noise

Lack of startle reflex to a loud noise

A nurse is assessing an adolescent who has a new diagnosis of anorexia nervosa. Which of the following findings should the nurse expect? A. Increased blood pressure B. Lanugo over the back C. Oily skin with acne D. Elevated body temperature

Lanugo over the back

A nurse is reviewing the laboratory report of a preschooler. Which of the following laboratory results should the nurse report to the provider? A. Potassium 4.2 mEq/L B. Lead 14 mcg/dL C. Fasting blood glucose 75 mg/dL D. Hematocrit 40%

Lead 14 mcg/dL

A nurse is reinforcing teaching about home care with the parents of an infant who has diaper dermatitis. Which of the following instructions should the nurse include? A. Dry the affected area with a hair dryer on the low setting twice per day B. Use cloth diapers washed in a low residue detergent C. Wash the genital area vigorously with each diaper change D. Leave the zinc oxide ointment intact and reapply as necessary during diaper changes

Leave the zinc oxide ointment intact and reapply as necessary during diaper changes

A nurse is caring for a preschooler who has a new diagnosis of asthma. Which of the following medications should the nurse instruct the parent to administer for an acute asthma attack? A. Levalbuterol B. Fluticasone C. Omalizumab D. Montelukast

Levalbuterol

A nurse is inspecting the eyes of a 5 day old infant. Which of the following is the correct technique for the nurse to use? A. Pull the conjunctiva downward and shine a pen light at the pupil B. Lift the infant's head while the infant is lying in a supine position C. Confirm that light reflects evenly off both pupils using the light of an otoscope D. Pull the eyelids upward individually and slowly bring the index finger toward the infant's nose

Lift the infant's head while the infant is lying in a supine position

A nurse is caring for a child who is terminally ill and who is nearing death. Which of the following interventions should the nurse perform? A. Discourage family members from leaving the child's bedside B. Limit provision of care to essential needs C. Insert a Foley catheter when urine output diminishes D. Decrease administration of routine pain medication

Limit provision of care to essential needs

A nurse is collecting data from the parents of a toddler. The nurse should identify that which of the following is a risk factor for lead poisoning in the toddler? A. Living in a home built in 1940 B. Reports of the toddler eating swordfish C. Multivitamin containers kept in a non-secured location D. Using fluorescent lighting in the home

Living in a home built in 1940

A nurse is caring for an infant who has gastroenteritis and is dehydrated. Which of the following characteristics places the infant at a higher risk for electrolyte imbalances compared to an adult client? A. Lower amount of extracellular fluid B. Reduced body surface area C. Longer intestinal tract D. Decreased rate of metabolism

Longer intestinal tract

A nurse is assisting with the care of an infant who has pertussis. Which of the following actions should the nurse take? A. Assess for edema of the extremities B. Apply warm compresses to the neck area C. Initiate airborne precautions D. Maintain a cardio-respiratory monitor

Maintain a cardio-respiratory monitor

A nurse is caring for a premature infant with respiratory distress syndrome. Which of the following actions should the nurse take? A. Place the infant in a supine position B. Administer caffeine via nasogastric tube once a day C. Feed the infant 5 to 10 mL every 3 hours D. Maintain oxygen saturation at 88% or above

Maintain oxygen saturation at 88% or above

A nurse is assisting with the immediate postoperative care of an 8 month old infant who had a cleft palate repair. Which of the following actions should the nurse perform? A. Maintain the infant in a side-lying position B. Provide non-pharmacological pain relief with a pacifier C. Offer pureed solid foods once the infant is awake and alert D. Assess the infant's pain level using the FACES Pain Rating Scale

Maintain the infant in a side-lying position

A nurse is contributing to the plan of care for a child who is in Buck's traction. Which of the following interventions should the nurse include in the plan? A. Remove the weights when changing the bed linens B. Maintain the leg in an extended position C. Monitor the halo device every 4 hr D. Provide pin care as prescribed.

Maintain the leg in an extended position

A nurse is preparing to assist a provider with a lumbar puncture for a school-aged child. Which of the following actions is the nurse's priority? A. Labeling collected specimens B. Providing reassurance to the child C. Maintaining the child's position D. Monitoring the child's vital signs

Maintaining the child's position

A nurse is caring for a school-aged child who is hospitalized with acute poststreptococcal glomerular nephritis (APSGN). Which of the following interventions should the nurse perform? A. Restrict the child's activity to bed rest only B. Measure the blood pressure every 4 hours C. Encourage oral fluid intake D. Place the child in droplet precautions

Measure the blood pressure every 4 hours

A nurse is caring for an infant who is experiencing dehydration. Which of the following data related to hydration status is the nurse's priority to collect? A. Measure the client's weight daily B. Observe tears C. Palpate the fontanel D. Check skin turgor

Measure the client's weight daily

A nurse is assisting with the care of an infant after a myelomeningocele repair. Which of the following is the priority postoperative action the nurse should take? A. Measure the infant's intake and output B. Measure the infant's head circumference C. Check the infant's lower-extremity function D. Monitor the infant's blood pressure

Measure the infant's head circumference

A nurse is reviewing laboratory findings of an adolescent who has acute renal failure. Which of the following findings should the nurse expect? A. Hypokalemia B. Hypercalcemia C. Decreased plasma creatinine level D. Metabolic acidosis

Metabolic acidosis

A nurse is contributing to the plan of care for a child who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions is the priority for the nurse to recommend? A. Monitor child's oxygen saturation level B. Administer prescribed antibiotics to the child C. Increase the child's fluid intake D. Apply warm compresses to the child's affected joints

Monitor child's oxygen saturation level

A nurse is assisting with the care of a client who has a major burn and is experiencing severe pain. Which of the following actions should the nurse take? A. Monitor morphine sulfate IV B. Monitor meperidine IM C. Administer acetaminophen PO D. Administer hydrocodone PO

Monitor morphine sulfate IV

A nurse is contributing to the plan of care for a school-aged child who is postoperative following a tonsillectomy. Which of the following interventions should the nurse include? A. Monitor the child for frequent clearing of the throat B. Give the child sips of water through a straw C. Encourage the child to clear copious secretion by blowing his nose D. Apply a warm washcloth to the child's throat to decrease pain

Monitor the child for frequent clearing of the throat

A nurse is caring for a 2 day old infant who has a myelomeningocele. Which of hte following actions should the nurse take? A. Monitor the infant's head circumference B. Position the infant supine C. Place the child under a radiant warmer D. Tape a piece of plastic over the protruding membranes

Monitor the infant's head circumference

A nurse is collecting data from a 6 month old infant. The guardian reports that the infant does not appear interested in the bright-colored mobile hanging above the crib. Which of the following techniques should the nurse use to check the infant's visual acuity? A. Shine a penlight briefly into the left and then the right eye B. Move a brightly colored toy from side to side in front of the infant's face C. Ask the guardian to sit in front of the infant and nod his head up and down D. Observe the infant's ability to grasp her feet and pull them to her mouth

Move a brightly colored toy from side to side in front of the infant's face

A nurse is reinforcing teaching about baclofen with the guardian of a toddler who has cerebral palsy. Which of the following adverse effects should the nurse include? A. Bradycardia B. Muscle weakness C. Diarrhea D. Dry skin

Muscle weakness

A nurse is performing a neurological examination on a 15 month old toddler. Which of the following findings should the nurse expect? A. Negative Babinski reflex B. Presence of the Moro reflex C. Absence of corneal reflexes D. Positive palmar grasp

Negative Babinski reflex

A nurse is reinforcing teaching with the parent of a toddler who has bacterial conjunctivitis. Which of the following instructions should the nurse include? A. Clean the secretions from the infected eye by wiping from the outer canthus towards the inner canthus and upward B. Keep the infected eye covered with warm compresses for the first 24 hours C. Notify the provider immediately if the sclera becomes inflamed D. Apply pressure to the outer canthus of the eye for 1 minutes after administration of the eye drops

Notify the provider immediately if the sclera becomes inflamed

A nurse is reinforcing teaching with a group of family members about communicable diseases. The nurse should include that which of the following is the best method to prevent a communicable disease? A. Hand washing B. Avoiding persons who have active disease C. Covering your cough D. Obtaining immunizations

Obtaining immunizations

A nurse is reinforcing anticipatory nutritional teaching with the caregivers of a 5 month old infant. Which of the following points should the nurse include in the teaching? A. Switch the infant from formula to low-fat cow's milk at 6 months of age B. Heat fruit juice before offering it to the infant C. Introduce a new food every other day D. Offer the infant finger foods such as crackers after 6 months of age

Offer the infant finger foods such as crackers after 6 months of age

A nurse is providing care to parents immediately following their child's unexpected death. Which of the following actions should the nurse take? A. Limit the amount of time the parents spend with the child's body B. Inform the parents that siblings should not view the body C. Offer the parents the opportunity to bathe and dress the child's body D. Avoid touching the parents when expressing sympathy

Offer the parents the opportunity to bathe and dress the child's body

A nurse is contributing to the plan of care for a toddler who has acute gastroenteritis and was recently admitted. Which of the following should the nurse plan to provide for the child? A. Oral rehydration solution B. Bananas or applesauce C. Chicken or beef broth D. Hypertonic IV solution

Oral rehydration solution

A nurse is reinforcing teaching with the guardians of a toddler who has a new prescription for an oral iron supplement. To increase the child's absorption of the iron, the nurse should recommend administering the supplement with which of the following? A. Eggs B. Orange juice C. Milk D. Oatmeal

Orange juice

A nurse is collecting data from an adolescent who is receiving fentanyl via epidural. Which of the following assessments should the nurse identify as the priority? A. Skin around the catheter site B. Blood pressure C. Pain level D. Oxygen saturation

Oxygen saturation

A nurse is caring for a child who has an exacerbation of cystic fibrosis. Which of the following laboratory findings should the nurse report to the provider immediately? A. Blood glucose 140 mg/dL B. Oxygen saturation 85% C. RBC 3.2 million/uL D. Serum sodium 156 mEq/L

Oxygen saturation 85%

A nurse is caring for a toddler who has a fever, a high-pitched cry, irritability, and vomiting. Which of the following actions should the nurse take? A. Administer 81 mg of aspirin to the toddler B. Give the toddler a cold bath C. Place the toddler a cold bath D. Pad the rails of the toddler's bed

Pad the rails of the toddler's bed

A nurse is reinforcing teaching with a caregiver about acetaminophen poisoning. Which of the following information should the nurse include? a. Nausea begins 24 hr after ingestion b. Pallor can appear as early as 2 hr after ingestion c. Jaundice will appear in 12 hr if the child is toxic d. Children can have 4 g/day of acetaminophen

Pallor can appear as early as 2 hr after ingestion

A nurse is contributing to the plan of care for an infant who has an unrepaired myleomeningocele. Which of the following actions should the nurse take? A. Fasten the diaper loosely B. Cleanse the meningeal sac with povidone-iodine daily C. Palpate the abdomen for bladder distension D. Cover the sac with a dry, sterile gauze dressing

Palpate the abdomen for bladder distension

A nurse is caring for a preschool-aged child who has an intussusception of the bowel. Which of the following findings should the nurse report to the physician? A. Passage of a formed brown stool B. Intermittent severe cramping pain C. Palpable mass in the right upper quadrant D. Bilious vomiting

Passage of a formed brown stool

A nurse is caring for an infant receiving phototherapy for hyperbilirubinemia. Which of the following should the nurse recognize as an indication of increased bilirubin excretion? A. Axillary temperature 37.6 C (99.7 F) B. Passage of several loose green stools C. Dry, peeling skin on the abdomen, hands, and feet D. Presence of Epstein pearls on the palate

Passage of several loose green stools

A nurse is assisting with an informational session about otitis media for a group of parents. Which of the following should the nurse identify as a risk factor for this illness? A. Summer months B. Breastfeeding C. Ages 7 to 10 years D. Passive smoking

Passive smoking

A nurse is caring for an infant in an acute care setting who has a tracheostomy. Which of the following interventions should the nurse perform when suctioning? A. Routinely suction the tracheostomy every 2 hours B. Pause for 60 seconds between suctioning attempts C. Limit suction time to <15 seconds D. Wear clean gloves when suctioning the tracheostomy

Pause for 60 seconds between suctioning attempts

A nurse is caring for the family of a preschooler who has a terminal illness. The nurse should advise the family to expect the preschooler to have which of the following concepts of death? A. People can come back to life after they die B. Death eventually occurs for all people C. Death is a scary monster that causes people to die D. People are unable to be anything but alive

People can come back to life after they die

A nurse is assisting with the care of an infant who has tracheoesophageal fistula. Which of the following actions should the nurse take? A. Place the infant in a lateral position B. Perform oropharyngeal suctioning C. Administer ranitidine orally D. Thicken the infant's formula

Perform oropharyngeal suctioning

A nurse is providing care for a 2 year old child in an acute care setting. Which of the following interventions will decrease the stress of hospitalization for a toddler? A. Keep the door to the child's room closed at all times B. Remove bandages as soon as possible C. Perform simple procedures in the playroom D. Perform procedures with the child sitting on his parent's lap

Perform procedures with the child sitting on his parent's lap

A nurse is assisting with the care of a school-aged child who has acute glomerulonephritis. Which of the following manifestations should the nurse expect? A. Hypokalemia B. Decreased blood pressure C. Increased urine volume D. Periorbital edema

Periorbital edema

A nurse is caring for a preschool-aged child who presents with manifestations of epiglottis. Which of the following actions is the nurse's priority to perform? A. Initiate droplet precautions B. Place resuscitation equipment on the child's bedside C. Provide blow-by humidified oxygen for the child D. Insert an intravenous catheter

Place resuscitation equipment on the child's bedside

A nurse is contributing to the plan of care for a toddler immediately following application of bilateral spica casts. Which of the following interventions should the nurse include? A. Allow the child to use an unsharpened pencil to scratch under the cast B. Place small pieces of moleskin over the cast edges to reduce irritation C. Maintain the toddler in a supine position for meals D. Observe the color of the toes every 8 hr for 24 hr

Place small pieces of moleskin over the cast edges to reduce irritation

A nurse is contributing to the plan of care for a child who has aplastic anemia. Which of the following interventions is the priority for the nurse to include? A. Pad the side rails of the child's bed with thick towels or blankets B. Place the child in a protective environment with positive air pressure C. Remove toys that have sharp corners or edges from the child's room D. Hold pressure on the child's puncture site for 5 minutes when obtaining blood samples

Place the child in a protective environment with positive air pressure

A nurse is caring for a 5 year old child who has a fever and begins to have a seizure. Which of the following actions should the nurse take? A. Give acetaminophen 240 mg PO immediately following the seizure B. Sponge the child's skin with a mixture of cold water and rubbing alcohol C. Administer rectal diazepam if the seizure lasts longer than 2 minutes D. Place the child in a side-lying position

Place the child in a side-lying position

A nurse is planning to administer the influenza vaccine to a toddler. Which of the following actions should the nurse take? A. Administer subcutaneously in the abdomen B. Use a 20 gauge needle C. Divide the medication into two injections D. Place the child in the supine position

Place the child in the supine position

A nurse is assisting with the care of a school-aged child who has skeletal traction applied to repair a pelvic fracture. Which of the following actions should the nurse take? A. Rest the child's traction weights on the floor for 8 hours during the night B. Ensure the child's meal tray contains no high fiber foods C. Perform passive range of motion exercises on the involved joints every 4 hours D. Place the child on a pressure-reduction mattress

Place the child on a pressure-reduction mattress

A nurse is assisting with the care of a client who has suspected meningitis and a decreased level of consciousness. Which of the following actions should the nurse take? A. Place the client on NPO status B. Prepare the client for a liver biopsy C. Position the client dorsal recumbent D. Put the client in a protective environment

Place the client on NPO status

A nurse is assisting with the care of an infant who has just returned from PACU following cleft lip and palate repair. Which of the following actions should the nurse take? A. Remove the packing in the mouth B. Place the infant in an upright position C. Offer a pacifier with sucrose D. Observe the mouth with a tongue blade

Place the infant in an upright position

A nurse is caring for a 4 month old infant who has tetralogy of Fallot and experiences a hypercyanotic spell. Which of the following actions should the nurse make? A. Place the infant in knee-chest position B. Begin CPR C. Prepare to intubate the infant D. Administer IV adenosine

Place the infant in knee-chest position

A nurse is assisting with the administration of a nasogastric enteral feeding for an infant. Which of the following actions should the nurse take? A. Place the infant in semi-Fowler's position for 1 hr after the feeding B. Flush the tube with 30 mL of normal saline before the feeding C. Warm the feeding in the microwave immediately prior to administration D. Auscultate over the infant's epigastric area to ensure proper tube placement

Place the infant in semi-Fowler's position for 1 hr after the feeding

A nurse is contributing to the plan of care for a 10 month old infant who is postoperative following a cleft palate repair. Which of the following actions should the nurse include in the plan of care? A. Place the infant in side-lying position B. Offer the infant liquids with a straw C. Prohibit the guardian from holding the infant for 8 hr D. Cleanse the suture line with a lemon glycerin swab

Place the infant in side-lying position

A nurse is reinforcing teaching with the guardian of a 10 year old child whose weight is in the 95th percentile on a growth chart. Which of the following instructions should the nurse include? A. Choose an exercise program for the child based on his abilities B. Plan a menu that provides the child with 1,200 calories each day C. Set a goal with the child to plan to lose weight over the next year D. Limit screen time to 3 hours per day

Plan a menu that provides the child with 1,200 calories each day

A nurse is collecting data from a 6 month old infant. Which of the following reflexes should the nurse expect the infant to exhibit? A. Moro B. Plantar grasp C. Stepping D. Tonic neck

Plantar grasp

A nurse is caring for a 4 month old child who is hospitalized. Which of the following playtime objects should the nurse provide for the child? A. Board book with large pictures B. Toy with moveable parts C. Plastic mirror D. Push-pull toy

Plastic mirror

A nurse is reviewing the laboratory report of a preschooler who has Wilms' tumor and is scheduled to begin treatment with an antineoplastic medication regimen. Which of the following laboratory results should the nurse report to the provider? A. BUN 16 mg/dL B. WBC count 5,500/mm3 C. serum glucose 98 mg/dL D. Platelet count 70,000

Platelet count 70,000

A nurse is reviewing the laboratory findings of a school-age child who reports feeling tired and being easily bruised. Which of the following laboratory values should the nurse report to the provider? A. Platelets 85,000/mm3 B. Hematocrit 39% C. Hemoglobin 14.2 g/dL D. RBC count 5 million/mm3

Platelets 85,000/mm3

A nurse is caring for a child who just experienced a generalized seizure. Which of the following is the priority action for the nurse to take? A. Position the child in a side-lying position B. Try and determine the seizure trigger C. Reorient the child to the environment D. Note the time of the postictal period

Position the child in a side-lying position

A nurse is assisting with the plan of care for a child who has hyperthermia. Which of the following actions should the nurse take? A. Administer antipyretics to the child every 4 to 6 hours B. Position the child on a cooling blanket and cover her with a sheet C. Place the child in a tube filled with water cooled to 26.7 to 29.4 C (80 to 85 F) D. Assess the child's temperature every 2 hours during the cooling process

Position the child on a cooling blanket and cover her with a sheet

A nurse is assisting with the care of a school-aged child who is having a tonic-clonic seizure. Which of the following actions should the nurse take first? A. Position the child on his side B. Measure the child's vital signs C. Loosen any restrictive clothing D. Check the child for head injuries

Position the child on his side

A nurse is caring for a 1 month old infant who has a nasogastric tube in place for intermittent feedings. Which of the following actions should the nurse take? A. Position the head of the crib at a 30 angle between feedings B. Place the infant on the left side after a feeding C. Administer feedings over 5 min D. Flush the tube with 30 mL of tap water

Position the head of the crib at a 30 angle between feedings

A nurse is preparing to perform a routine heel puncture on a newborn. Which of the following actions should the nurse take? A. Administer tolmetin prior to the procedure B. Apply a eutectic mixture of local anesthetics (EMLA) cream to the newborn's heel after the procedure C. Prepare concentrated sucrose for oral administration D. Place the newborn in an extended position

Prepare concentrated sucrose for oral administration

A nurse in an urgent in an urgent care clinic is caring for a child whose guardian reports that the child has swallowed paint thinner. The child is lethargic, gagging, and cyanotic. Which of the following actions should the nurse anticipate assisting with? a. Induce vomiting with syrup of ipecac b. Insert a nasogastric tube, and administer activated charcoal c. Prepare for intubation with a cuffed endotracheal tube d. Administer chelation therapy using deferoxamine mesylate

Prepare for intubation with a cuffed endotracheal tube

A nurse is caring for a preschooler who experienced a febrile seizure. Which of the following actions should the nurse take? A. Place the child in a bathtub filled with cool water B. Immediately administer an oral antipyretic medication C. Prepare the child for a lumbar puncture D. Apply alcohol soaks to the child's forehead and groin area

Prepare the child for a lumbar puncture

A nurse is caring for a child who has Hirschsprung's disease. Which o the following actions should the nurse take? A. Encourage a high-fiber, low-protein, low-calorie diet B. Prepare the family for surgery C. Place an NG tube for decompression D. Initiate bed rest

Prepare the family for surgery

A nurse working in the emergency department is caring for a 6 month old infant who has a new diagnosis of respiratory syncytial virus (RSV). The parent tells the nurse, "My baby won't even drink half of a bottle of formula." Which of the following actions should the nurse take? A. Check the infant's sucking reflex B. Perform routine chest physiotherapy (CPT) C. Prepare to administer intravenous fluids D. Place the infant in a negative-pressure isolation room

Prepare to administer intravenous fluids

A nurse working in the emergency department is caring for a 6 month old infant who has a new diagnosis of respiratory syncytial virus (RSV). The parent tells the nurse, "My baby won't even drink half of a bottle of formula." Which of the following actions should the nurse take? A. Evaluate the infant's sucking reflex B. Suction the infant's airway before trying to administer a bottle feeding C. Prepare to administer intravenous fluids D. Place the infant in a negative-pressure isolation room

Prepare to administer intravenous fluids

A nurse is reinforcing teaching with a caregiver of a preschool child about factors that affect the child's perception of death. Which of the following factors should the nurse include? A. Preschool children have no concept of death B. Preschool children perceive death as temporary C. Preschool children often regress to an earlier stage of behavior D. Preschool children experience fear related to the disease process

Preschool children perceive death as temporary

A nurse is collecting data from an infant who has pyloric stenosis. Which of the following manifestations should the nurse expect? A. Projectile vomiting B. Rigid board-like abdomen C. Mucus in the stools D. Jaundice

Projectile vomiting

A nurse is assisting with the care of an infant who is preoperative for the treatment of an intact myelomeningocele sac. In which of the following positions should the nurse place the infant? A. Side-lying B. Supine C. Prone D. Semi-Fowler's

Prone

A nurse is collecting data from a child who has short stature. Which of the following findings would indicate a growth hormone deficiency? A. Proportional height to weight B. Height proportionally greater than weight C. Oversized jaw D. Early-onset puberty

Proportional height to weight

A nurse is assisting with planning dietary needs for a toddler. Which of the following interventions should the nurse include in the plan of care? A. Give the toddler 1/2 cup (113 g) of fruit daily B. Encourage the toddler to drink 8 oz (236.6 mL) of juice daily C. Give the child 40 oz (1.2 L) of milk daily D. Provide 1 Tbsp (15 g) of solid food for each year of age

Provide 1 Tbsp (15 g) of solid food for each year of age

A nurse is reinforcing dietary teaching with the parent of a toddler who has cystic fibrosis. Which of the following instructions should the nurse include? A. Provide a high-fat diet for the toddler B. Limit the toddler's daily intake of sodium C. Increase the toddler's intake of foods high in folic acid D. Allow the toddler to skip meals when he is not hungry

Provide a high-fat diet for the toddler

A nurse is caring for a school-aged child who has sickle cell anemia. Which of the following actions should the nurse take to help decrease the child's risk of experiencing a vaso-occlusive crisis? A. Provide adequate fluid intake throughout the day B. Provide oxygen at 2 L/min via nasal cannula C. Administer a blood transfusion D. Give ibuprofen to manage pain

Provide adequate fluid intake throughout the day

A nurse is preparing to administer immunizations to a 4 month old infant. Which of the following actions should the nurse take to provide atraumatic care? A. Administer 81 mg of aspirin B. Use the Z-track method when injecting C. Ask the guardians to leave the room during the injection D. Provide sucrose solution on the pacifier

Provide sucrose solution on the pacifier

A nurse is a care provider's office is preparing to administer scheduled vaccines to an infant. The infant's parent refuses to allow the nurse to administer the vaccines. Which of the following actions should the nurse take? A. Ask the parent why they do not want the vaccines to be administered B. Provide the parent with a vaccine information sheet (VIS) C. Question the parent if their other children are vaccinated D. Tell the parent that the vaccines must be completed at the next visit

Provide the parent with a vaccine information sheet (VIS)

During a well-child visit, the guardian of a toddler expresses a concern that the toddler take several hours to fall asleep at night. Which of the following recommendations should the nurse make? A. Vary the time the toddler goes to bed each night B. Allow the toddler to watch television before bedtime C. Provide the toddler with a favorite stuffed animal at bedtime D. Increase the toddler's activity prior to bedtime

Provide the toddler with a favorite stuffed animal at bedtime

During a well child visit, the parent of a toddler expresses concern to the nurse that the toddler takes several hours to fall asleep a night. Which of the following recommendations should the nurse make? A. Vary the time the toddler goes to bed each night B. Allow the toddler to watch television before bedtime C. Provide the toddler with a favorite toy at bedtime D. Increase the toddler's activity prior to bedtime

Provide the toddler with a favorite toy at bedtime

A nurse is planning care for a 4 year old child who has nephrotic syndrome. Which of the following actions should the nurse include? A. Provide thorough skin care B. Test for blood type and cross-match C. Allow ample hydrating fluids D. Maintain a low-carbohydrate diet

Provide thorough skin care

A nurse is caring for an adolescent client who has a prescription for opioids. Which of the following findings should the nurse recognize as an adverse effect of opioids? A. Dilated pupils B. Tremors C. Yawning D. Pruritis

Pruritis

A nurse is caring for an infant who needs otic medication. Which of the following is an appropriate action for the nurse to take? A. Hold the infant in an upright position B. Pull the pinna downward and straight back C. Hyperextend the infant's neck D. Ensure that the medication is cool

Pull the pinna downward and straight back

A nurse is discussing play activities with a group of parents of toddlers. Which of the following activities should the nurse recommend for this age group? A. Jumping rope B. Pushing a toy lawn mower C. Sorting colored marbles D. Playing a board game

Pushing a toy lawn mower

A nurse is reinforcing teaching with the parents of a 2 year old toddler at a well child visit. Which of the following should the nurse recommend as an age-appropriate activity for the toddler? A. Creating a rock collection B. Learning the alphabet with flash cards C. Putting together a large piece puzzle D. Riding a tricycle

Putting together a large piece puzzle

A nurse is contributing to the plan of care for a preschooler who was admitted for the treatment of measles. Which of the following activities should the nurse recommend for the child? A. Constructing a model airplane B. Playing a video game in the playroom C. Pulling a wagon with toys in the hallway D. Putting together a puzzle with large pieces

Putting together a puzzle with large pieces

A nurse is caring for a child who has acute lymphocytic leukemia. Which of the following laboratory values should the nurse expect? A. Platelet count 500,000/mm3 B. RBC 2.5 million/uL C. WBC 4,000/mm3 D. Hct 60%

RBC 2.5 million/uL

A nurse is caring for a child who has tetralogy of Fallot. Which of the following laboratory values should the nurse expect? A. Platelet count 20,000/mm3 B. WBC 4,000/mm3 C. TSH 7.0 microunits/mL D. RBC 6.8 million/uL

RBC 6.8 million/uL

A nurse is caring for a child who is suspected of having Legg-Calve-Perthes disease. The nurse should prepare the child for which of the following diagnostic procedures? A. Bone biopsy B. Genetic testing C. CT scan D. Radiographs

Radiographs

A nurse is caring for an adolescent whose guardian expresses concerns about the child sleeping such long hours. Which of the following conditions should the nurse inform the guardian as requiring additional sleep during adolescence? A. Sleep terrors B. Rapid growth C Elevated zinc levels D. Slowed metabolism

Rapid growth

A nurse is reviewing the medical record of a client who has Reye syndrome. Which of the following findings should the nurse identify as a risk factor for Reye syndrome? A. Recent history of infectious cystitis caused by Candida B. Recent history of bacterial otitis media C. Recent episode of gastroenteritis D. Recent episode of Haemophilus influenzae meningitis

Recent episode of gastroenteritis

A nurse is assisting with planning care for a school age child who has increased intracranial pressure. Which of the following actions should the nurse include in the plan of care? A. Elevate the head of the bed to a 45 angle B. Turn the child from side to side frequently C. Reduce environmental stimuli D. Suction oral secretions every hour

Reduce environmental stimuli

A nurse is caring for a preschooler. Which of the following is an expected behavior of a preschool-age child? A. Describing manifestations of illness B. Relating fears to magical thinking C. Understanding cause of illness D. Awareness of body functioning

Relating fears to magical thinking

A nurse is collecting data on a toddler at a well child visit. Which of the following observations should the nurse report to the provider as a potential manifestation of an autism spectrum disorder? A. Playing alongside but not with other children B. Speaking using only 2 or 3 words phrases C. Reluctance to make eye contact D. Displaying temper tantrums

Reluctance to make eye contact

A nurse is reinforcing teaching about home safety with the parent of a 2 month old infant. Which of the following information should the nurse include? A. Remove bibs before the infant goes to sleep B. Cover the infant with a lightweight blanket at bedtime C. Place the infant in direct sunlight for at least 10 minutes each day D. Set the hot water to 60 C (140 F)

Remove bibs before the infant goes to sleep

A nurse is contributing to the plan of care for a newborn who has hyperbilirubinemia and is scheduled to receive phototherapy. Which of the following interventions should the nurse include? a. Reposition the newborn every 4 hr b. Lotion the newborn's skin twice per day c. Check the newborn's temperature every 8 hr d. Remove the newborn's eye mask during feedings

Remove the newborn's eye mask during feedings

A nurse is reinforcing teaching with an adolescent about various strategies for chronic pain management. Which of the following activities should the nurse use as an example of the non-pharmacological strategy to thought-stopping? A. Assemble a puzzle B. Discuss a recent pleasurable event C. Tighten and then relax each body part D. Repeat memorized facts about the painful event

Repeat memorized facts about the painful event

A nurse is planning to perform chest physiotherapy (CPT) for an infant who has cystic fibrosis. Which of the following techniques should the nurse plan to include? A. Repeatedly strike the infant's chest using a cupped hand B. Administer the CPT 30 minutes after each C. Position the infant prone to drain the apical segment of the left upper lobe D. Hyperoxygenate the infant before initiating CPT

Repeatedly strike the infant's chest using a cupped hand

A newly licensed nurse in an urgent care center for a child who has bruises that raise suspicion for child abuse. Which of the following actions should the nurse take? A. Ask the child if his parents are responsible for the abuse B. Notify the facility's risk manager C. Interview the child with his parents absent D. Report the suspected abuse to local authorities

Report the suspected abuse to local authorities

A nurse is collecting data from an adolescent who has manifestations of physical abuse. Which of the following actions should the nurse take? A. Conduct the admission process with the adolescent's parent at bedside B. Report the suspected abuse to the authorities C. Use closed-ended questioning when speaking with the adolescent D. Encourage the adolescent to enroll in family psychotherapy

Report the suspected abuse to the authorities

A nurse is collecting data from a 9-month-old infant. Which of the following findings should the nurse report to the provider as a delay in development? A. Using a pincer grasp to pick up blocks B. Requiring support to sit for prolonged time C. Turning the head toward the parent's voice D. Reaching for the mother and saying "mama"

Requiring support to sit for prolonged time

A nurse is checking the vital signs of a 3-year-old child during a well-child visit. Which of the following findings should the nurse report to the provider? A. Temperature 37.2 C (99.0 F) B. Heart rate 106/min C. Respirations 35/min D. Blood pressure 88/54 mm Hg

Respirations 35/min

A nurse is collecting date from a child who is postoperative. Which of the following findings should the nurse identify as an indication that naloxone should be administered? A. Crackles in the lung bases B. Respiratory depression C. Nausea and vomiting D. Tachycardia

Respiratory depression

A nurse is collecting data for an adolescent who has asthma and has received an albuterol nebulizer treatment. Which of the following findings indicates an improvement in the adolescent's condition? A. Temperature 38.1 C (100.5 F) B. Respiratory rate 20/min C. SaO2 91% D. Bilateral wheezing

Respiratory rate 20/min

A nurse is caring for a toddler who is postoperative following a cleft palate repair. Which of the following actions should the nurse take? A. Restrain the toddler's arms at the elbows B. Feed the toddler with a spoon C. Monitor the toddler's oral temperature D. Weigh the toddler every 48 hours

Restrain the toddler's arms at the elbows

A nurse is contributing to the plan of care for a school-age child who has acute poststreptococcal glomerulonephritis (APSGN) and is mildly hypertensive. Which of the following actions should the nurse include in the plan of care? A. Restrict the child's sodium intake B. Weigh the child every other day C. Monitor the child's blood pressure every 12 hour D. Place the child on bed rest

Restrict the child's sodium intake

A nurse is collecting data from a 3 year old child during a well child visit. Which of the following gross motor skills should the nurse expect the child to perform? A. Ride a tricycle B. Hop on one foot C. Jump rope D. throw a ball overhead

Ride a tricycle

A nurse is collecting data for an adolescent who presents with manifestations of appendicitis. Which of the following manifestations should the nurse expect? A. Upper right quadrant abdominal pain B. Rigid abdomen C. Hyperactive bowel sounds D. Bradycardia

Rigid abdomen

A nurse is preparing a school-aged child for a tonsillectomy. Which of the following actions should the nurse take? A. Schedule the child for a preoperative visit to the facility B. Inform the child she will put to sleep during the procedure C. Read the child a story about a cartoon character having a similar operation D. Tell the child appointment is to have her throat checked

Schedule the child for a preoperative visit to the facility

A nurse is planning to assist with health screenings for a group of young adolescent clients. For which of the following health screenings should the nurse plan to collect data? A. Lead poisoning screening B. Autism screening C. Developmental screening D. Scoliosis screening

Scoliosis screening

A nurse is reinforcing teaching with the parents of preschoolers regarding the use of booster seats in a motor vehicle. Which of the following instructions should the nurse include in the teaching? A. Ensure the shoulder-lap portion of the seat belt fits across the child's abdomen when sitting in the booster seat B. Use a no-back, belt positioning booster seat if the motor vehicle does not have head rests C. Discontinue using a booster seat when the child is 135 cm (4 feet 5 in) in height D. Secure the child in the booster seat using the motor vehicle's shoulder-lap seat belt

Secure the child in the booster seat using the motor vehicle's shoulder-lap seat belt

A nurse is reinforcing teaching about the management of epistaxis to an adolescent. Which of the following positions should the nurse instruct the adolescent to take when experiencing a nosebleed? A. Sit up and lean forward B. Sit up and tilt the head up C. Lie in a supine position D. Lie in a prone position

Sit up and lean forward

A nurse is collecting data from a 10 month old infant. Which of the following findings should the nurse report to the provider? A. Pulls self to standing position B. Moves by creeping on hands and knees C. Takes intentional steps when standing D. Sits with support by leaning on hands

Sits with support by leaning on hands

A nurse is collecting data from an infant who has acute gastroenteritis. Which of the following findings should the nurse identify as a manifestation of severe dehydration? A. Weight loss of 5% B. Mild irritability C. Capillary refill of 3 seconds D. Skin that is cool to the touch

Skin that is cool to the touch

A nurse is reviewing the laboratory values for a 6 month old infant who has acute renal failure. Which of the following findings should the nurse expect A. BUN 5 mg/dL B. Creatinine 0.2 mg/dL C. Sodium 125 mEq/L D. Potassium 4.2 mEq/L

Sodium 125 mEq/L

A nurse is reviewing the laboratory report of a school-age child who is receiving prednisone. Which of the following laboratory results should the nurse report to the provider? A. Fasting blood glucose 74 mg/dL B. Sodium 150 mEq/L C. Potassium 4.2 mEq/L D. WBC count 9,400/mm3

Sodium 150 mEq/L

A nurse is collecting data from an infant who is receiving IV therapy for fluid replacement. Which of the following findings indicates the infant's status is improving? A. WBC count 19,000/mm3 B. Sodium level 145 mEq/L C. Capillary refill greater than 3 seconds D. Dry mucous membranes

Sodium level 145 mEq/L

A nurse is reinforcing teaching with the guardian of a school-aged child who has hearing loss. Which of the following techniques should the nurse recommend to facilitate communication with the child? A. Exaggerate the pronunciation of each word B. Keep hands still when speaking C. Speak at the child's eye level D. Avoid using facial expressions when speaking

Speak at the child's eye level

A nurse is collecting data from a 4 year old child for growth and developmental milestones during a well-child visit. Which of the following findings suggest a possible delay in development? A. Inability to ties shoes B. Adding 3 parts to a stick figure C. Speaking using 2- or 3-word sentences D. Inability to walk backward

Speaking using 2- or 3-word sentences

A nurse is caring for a toddler who has had three ear infections in the past 5 months. The nurse should identify that this places the toddler at risk for developing which of the following long-term complications? A. Balance difficulties B. Rash C. Speech delays D. Mastoiditis

Speech delays

A nurse is caring for an 18 month old infant who has chronic otitis media. The nurse should recognize that chronic otitis media will affect which of the following? A. Olfaction B. Visual acuity C. Speech patterns D. Hand-eye coordination

Speech patterns

A nurse is reinforcing teaching with the parents of a 7 year old female child about behavioral expectations. Which of the following behaviors should the nurse include in the teaching? A. Spends a lot of time by herself B. Exhibits a decline in self-esteem C. Selectively chooses a best friend D. Shows a competitive nature with others

Spends a lot of time by herself

A nurse is caring for a child who has AIDS. Which of the following isolation precautions should the nurse initiate? A. Contact B. Airborne C. Droplet D. Standard

Standard

A nurse is checking the gross motor development of a 3 year old child. Which of the following skills should the nurse expect the child to perform? A. Skipping around the room B. Hopping on 1 foot C. Throwing a ball overhead D. Standing on 1 foot

Standing on 1 foot

A nurse is assisting the provider with a developmental assessment of a toddler. Which of the following behaviors should the nurse recognize as an expected finding? A. Walks backwards with heel to toe B. Stands on one foot for several seconds C. Uses scissors to cut out shapes D. Prints letters with a pencil

Stands on one foot for several seconds

A nurse is collecting data for a school-aged child who has cystic fibrosis. Which of the following manifestations should the nurse expect? A. Pruritus B. Pyrosis C. Tinnitus D. Steatorrhea

Steatorrhea

A nurse is collecting data from a school-aged child who has celiac disease. Which of the following findings should the nurse expect? A. Elevated sweat chloride B. Steatorrhea C. Clubbing of the fingers D. Jaundice

Steatorrhea

A nurse is reinforcing teaching with the parents of a 1 year old infant regarding appropriate play activities for this age group. Which of the following activities should the nurse include? A. Pull-push toy with a cord B. Simple craft project C. Soft doll filled with dried beans D. Strings of large beads

Strings of large beads

A nurse is admitting a child who has a history of tonic-clonic seizures. Which of the following items is the priority to have in the child's room? A. pulse oximeter B. Oxygen therapy C. Bag valve mask D. Suction equipment

Suction equipment

A nurse is contributing to the plan of care for an infant who has bronchiolitis and is tachypneic. Which of the following actions should the nurse include in the plan of care? A. Provide high flow oxygen via facemask B. Implement chest percussion every 2 hr C. Suction nasal passages with a bulb syringe D. Initiate airborne precautions

Suction nasal passages with a bulb syringe

A nurse is caring for a school-aged child who has appendicitis. Which of the following findings should the nurse report to the physician? A. Temperature of 38 C (100.4 F) B. McBurney point tenderness C. Nausea and vomiting D. Sudden decrease in pain level

Sudden decrease in pain level

A nurse is caring for an adolescent client whose weight is in the 76th percentile on a growth chart. Which of the following recommendation should the nurse make? A. Tell the client not to drink any sugar-sweetened drinks B. Instruct the parents to limit the adolescent's screen time to 30 hours per week C. Recommend that the family eat at restaurants that have salad bars available D. Suggest ways the family can participate in mealtimes together

Suggest ways the family can participate in mealtimes together

A nurse is caring for a 4 year old child who has superficial partial thickness burns over 50% of his body. To meet the nutritional needs of the child, which of the following actions should the nurse plan to take? A. Administer pancrelipase to the child to each meal B. Supplement the child's feedings with enteral feedings C. Provide the child with a low-protein meal D. Perform dressing changes 10 minutes prior to the child's meals

Supplement the child's feedings with enteral feedings

A nurse is caring for an infant who has neonatal abstinence syndrome (NAS). Which of the following interventions should the nurse perform? A. Provide socialization for the infant at the nurse's station B. Swaddle the infant snugly with arms flexed C. Discourage the parent from holding the infant during the acute withdrawal phase D. Monitor the infant for signs of constipation

Swaddle the infant snugly with arms flexed

A nurse is reviewing the diagnostic findings for a preschool age child who is suspected of having cystic fibrosis. Which of the following findings should the nurse identify as an indication of cystic fibrosis? A. Sweat chloride content 85 mEq/L B. Increased blood levels of fat-soluble vitamins C. 72 hr stool analysis sample indicating hard, packed stools D. Chest x-ray negative for atelectasis

Sweat chloride content 85 mEq/L

A nurse is collecting data from a child who has type 1 diabetes mellitus. Which of the following findings should the nurse identify as a manifestation of hypoglycemia? A. Tachypnea B. Dry mouth C. Flushed skin D. Tachycardia

Tachycardia

A nurse is collecting data from an infant who has a respiratory infection. Which of the following findings is an early indication of acute hypoxemia? A. Nonproductive cough B. Hypoventilation C. Tachypnea D. Nasal stuffiness

Tachypnea

A nurse is reinforcing teaching with a 9 year old child who desires to learn to swallow pills. Which of the following instructions should the nurse include? A. Instruct the child to tuck the chin when swallowing a pill B. Teach the child to practice swallowing small bits of ice first C. Hide the pill in soft food and praise the child after the child swallows the pill D. Discourage the child from trying to swallow medication until adolescence

Teach the child to practice swallowing small bits of ice first

A nurse is caring for a 2 year old who has a history of frequent urinary tract infections. When reinforcing teaching with the parents about the prevention of urinary tract infections, which of the following instructions should the nurse include? A. Teach the child to wipe from front to back B. Give the child frequent bubble baths C. Urge the child to urinate every 6 hours D. Administer oxybutynin daily

Teach the child to wipe from front to back

A nurse in a provider's office receives a phone call from the guardian of an infant who just vomited after the administration of digoxin. Which of the following actions should the nurse take first? A. Tell the guardian that a repeat dose of medication should not be given B. Verify the prescribed medication regimen C. Determine if the infant has been exposed to others who are ill D. Ask the guardian about the infant's urinary output

Tell the guardian that a repeat dose of medication should not be given

A nurse is collecting data from an infant who is experiencing respiratory distress, absence of breath sounds on a side, and deviation of the trachea away from the affected side. The nurse should identify that the infant is experiencing which of the following conditions? A. Tension pneumothorax B. Flail chest C. Pulmonary contusion D. Fractured rib

Tension pneumothorax

A nurse is collecting data from a child who sustained a head injury. During the assessment, the nurse observes clear drainage leaking from the child's nose. Which of the following actions should the nurse take? A. Perform nasotracheal suctioning B. Test the nasal secretions for glucose C. Maintain direct lighting on the child D. Lower the head of the bed

Test the nasal secretions for glucose

A nurse is assisting teaching a class about puberty in boys. Which of the following should the nurse include as the first manifestation of sexual maturation? A. pubic hair growth B. Vocal changes C. Testicular enlargement D. Facial hair growth

Testicular enlargement

A nurse is reinforcing preconception teaching with a client whonhas phenylketonuria (PKU). Which of the following information should the nurse include? a. Follow a low-phenylalanine diet once pregnancy is confirmed b. Testing of phenylalanine levels will be required one to two times per week throughout pregnancy c. Increase intake of dietary proteins prior to conception d. Cesarean birth will be required due to the likelihood of having a fetus with macrosomia

Testing of phenylalanine levels will be required one to two times per week throughout pregnancy

A nurse in a clinic is collecting data from an adolescent who has received all recommended immunizations through the age of 6 years. Which of the following immunizations should the nurse plan to administer? A. Haemophilus influenza type b (Hib) B. Rotavirus (RV) C. Polio (IPV) D. Tetanus, diphtheria toxoids, and acellular pertussis (Tdap)

Tetanus, diphtheria toxoids, and acellular pertussis (Tdap)

A nurse is assessing a 3 year old child during a well-child examination. Which of the following findings should the nurse report to the provider? A. The child wets the bed when sleeping B. The child cannot catch a ball C. The child cannot walk on tiptoe D. The child builds a tower of 10 cubes

The child cannot walk on tiptoe

A nurse is assisting with a history-taking and physical of a school-aged child who has attention deficit hyperactivity disorder (ADHD). Which of the following findings in the child's medical record should the nurse identify as a risk factor for ADHD? A. The child's family has a middle-class socioeconomic background. B. The child had prenatal exposure to alcohol on a regular basis C. Both siblings of the child show moderate activity levels in school and play activities D. The child's mother currently has diabetes mellitus

The child had prenatal exposure to alcohol on a regular basis

A nurse is reviewing the dynamics of a family in which abuse is suspected. Which of the following findings should the nurse report to the provider? A. The parents provide emotional support to the child during the assessment process B. The child has several unexplained scars and bruises C. The child cries and appears afraid of the health care provider D. The parents offer consistent, detailed stories about the child's injuries

The child has several unexplained scars and bruises

A nurse in the outpatient setting is planning to administer the varicella vaccine to a toddler. Which of the following findings is a contraindication to the child receiving this vaccination? A. The child is displaying manifestations of a cold B. The child has a sibling with autism C. The child is receiving chemotherapy D. The child has a documented allergy to eggs

The child is receiving chemotherapy

A nurse is collecting data from a 6 year old child who is immediately postoperative following a tonsillectomy. Which of the following findings should the nurse report to the provider? A. The child has a small amount of dark brown between the teeth B. The child is swallowing frequently C. The child has a heart rate of 118/min D. The child refuses the application of an ice collar

The child is swallowing frequently

A nurse in an acute pediatric unit is caring for a 2 year old child who has separation anxiety when her parents leave for work. The nurse should identify which of the following behaviors as a manifestation of the stage of despair? A. The child tries to bite the nurse B. The child is withdrawn and refuses to talk C. The child attempts to run away to find her parents D. The child screams and cries loudly

The child is withdrawn and refuses to talk

A nurse is preparing to assist with the physical assessment of a 2 year old toddler. Which of the following behaviors should the nurse expect during the examination? A. The child prefers to sit on the parent's lap during the examination B. The child is interested in how the examination equipment works C. The child asks specific questions about body functions D. The child questions how her development compares to other children at the same age

The child prefers to sit on the parent's lap during the examination

A nurse is caring for a school-aged child who had an arm cast applied 8 hours ago. Which of the following findings should alert the nurse to a complication related to the casting? A. The child reports a pain level of 5 on a scale of 0 to 10 B. The child's hands are cool bilaterally C. The child reports tightness at the wrist D. The child's grasp is weak

The child reports tightness at the wrist

A nurse is collecting physical data from a 4 year old child who has diarrhea and has been vomiting for 24 hr. Which of the following sites should the nurse grasp to determine the child's skin turgor? A. The child's sacral area B. The top of the child's hand C. The child's sternal area D. The child's abdomen

The child's abdomen

A nurse in a pediatric clinic is collecting data from a preschooler during a well-child visit. Which of the following findings should the nurse report to the provider? A. The child is sitting on the exam table and talking to a stuffed animal B. The child's blood pressure is 122/80 mmHg C. The child is crying and states, "I don't want any medicine." D. The child's respiratory rate is 22/min

The child's blood pressure is 122/80 mmHg

A nurse is collecting data about the dietary habits of an adolescent female client. The nurse should identify that which of the following findings puts the client at risk for nutritional deficits? A. The client chooses to eat more vegetables than fruits B. The client consumes approximately 2,000 calories a day C. The client fasts twice a week to manage dietary intake D. The client increases their dietary intake during track season

The client fasts twice a week to manage dietary intake

A nurse is assisting with evaluating an adolescent client who was treated for syphillis. Which of the following indicates the treatment was effective? A. The client reports an episode of fever for 24 hours B. The chancre heals and disappears C. The client denies vaginal discharge D. The lesions become gangrenous and slough off

The client reports an episode of fever for 24 hours

A nurse is discussing disciplinary techniques with the guardian of a preschooler. Which of the following actions indicates to the nurse that the guardian is using an age-appropriate disciplinary technique? A. The guardian explains to the child why her behavior is unacceptable B. The guardian places the child in time-out after misbehaving C. The guardian allows the child to choose the consequence of her misbehavior D. The guardian assigns an extra chore for the child's misbehavior

The guardian places the child in time-out after misbehaving

A nurse is caring for a 4 week old infant who is 2 weeks postoperative following surgical correction of biliary atresia. Which of the following findings is an indication that the surgery was successful? A. The infant has lost 2.2 kg (1 lb) since the surgery B. The infant has a total bilirubin level of 0.3 mg/dL C. The infant has an aspartate aminotransferase (AST) level of 120 units/L D. The infant's stools are gray in color

The infant has a total bilirubin level of 0.3 mg/dL

A nurse is preparing a 3 month old infant for a wellness visit with the physician. Which of the following observations should the nurse expect? A. The infant looks at his hands B. The infant has a pincer grasp C. The infant has no head lag when pulled to a sitting position D. The infant can independently roll from his back to his abdomen

The infant looks at his hands

A nurse is collecting data from a 10 month old infant at a well infant checkup. Which of the following assessment findings should the nurse report to the provider? A. The infant is unable to walk independently B. The infant's Moro reflex is absent C. The infant's anterior fontanel is open D. The infant needs assistance to sit up

The infant needs assistance to sit up

A nurse in a provider's office enters an examination room to collect data from an 8 month old infant for the first time. Which of the following reactions by the infant should the nurse expect? A. The infant gives the nurse a social smile B. The infant turns away when the nurse approaches C. The infant reaches out the nurse to be held D. The infant is responsive and alert as the nurse comes closer

The infant turns away when the nurse approaches

A nurse is collecting data from a 12 month old infant during a well child checkup. Which of the following findings should the nurse report to the provider? A. The infant's current weight is double his birth weight B. The infant's posterior fontanel is closed C. The child is unable to walk without support D. A total of 6 teeth are present

The infant's current weight is double his birth weight

A nurse is assisting with the development of a health promotion program for the guardians of adolescents. Which of the following information about adolescents should the nurse recommend to include in the program? A. The sleep patterns of adolescents are well established B. The percentage of adolescents that consider suicide is higher for males than for females C. The leading cause of death in adolescents is physical injury D. The caloric intake needs of adolescence are less than that of school-age children

The leading cause of death in adolescents is physical injury

A nurse is collecting data from an 18 month old toddler. Which of the following is a deviation from expected growth and development that the nurse should report to the provider? A. The toddler is unable to recognize familiar objects by name B. The toddler is unable to dress himself in simple clothing C. The toddler is unable to talk in complete sentences D. The toddler is unable to draw a circle

The toddler is unable to recognize familiar objects by name

A nurse is assessing an 18 month old toddler during a well child examination. Which of the following findings should the nurse report to the provider? A. The toddler is unable to remove his shoes B. The toddler is unable to draw a plus sign C. The toddler is unable to jump off a step D. The toddler is unable to turn 1 page of a book at a time

The toddler is unable to remove his shoes

A nurse is collecting data from a school-aged child who reports horseback riding 3 times per week and has injuries reportedly related to a fall from a horse. Which of the following findings should the nurse investigate further as an indication of child maltreatment? A. Bruising of the right elbow B. Dislocated left shoulder revealed by X-ray C. Thin, frail extremities D. Abrasions on both wrists

Thin, frail extremities

A school nurse is collecting data from an adolescent child who returned to school following a case of mononucleosis. The child has a note from his provider excusing him from gym class. Which of the following findings should the nurse identify as the reason for this excusal? A. To reduce the potential of sustaining abdominal trauma B. To mitigate a deficient dietary intake C. To avoid exposing peer to the illness D. To avoid straining sore joints

To reduce the potential of sustaining abdominal trauma

A nurse in a provider's office is observing children playing in the waiting room. The nurse should expect to identify parallel behavior in which of the following age groups? A. Infants B. Toddlers C. Preschoolers D. School-aged children

Toddlers

A nurse at a community health department is discussing the nutritional needs of children with a group of parents and guardians. Which of the following pieces of information should the nurse include? A. Infants should be transitioned to low-calorie milk at 12 months B. Preschoolers need 10 to 12 g of protein per day C. Toddlers can be given up to 120 to 180 mL (4 to 6 oz) of juice per day D. School-aged children should be encouraged to avoid afternoon snacks

Toddlers can be given up to 120 to 180 mL (4 to 6 oz) of juice per day

A hospice nurse is assisting with a support group for parents of toddlers who have a terminal illness. Which of the following pieces of information should the nurse reinforce in the teaching? A. Toddlers will react to the parent's anxiety and sadness B. Toddlers view death as a punishment for bad behavior C. Toddlers view death as permanent and irreversible D. Toddlers have a realistic concept of death

Toddlers will react to the parent's anxiety and sadness

A nurse is caring for a group of infants who have congenital heart defects. For which of the following defects should the nurse expect to obseve cyanosis? A. Transposition of great arteries B. Ventricular-septal defect C. Coarctation of the aorta D. Patent ductus of great arteries

Transposition of great arteries

A nurse is collecting data from a toddler who has Down syndrome. Which of the following findings should the nurse expect? A. Transverse palmar crease B. Hyperreflexia C. Scaphoid abdomen D. Tight frenulum

Transverse palmar crease

A nurse is reinforcing teaching with the guardian of a child who has a new diagnosis of enterobiasis. The nurse should advise the guardian to take which of the following actions to prevent infection? A. Dress the child in two-piece sleeping outfits B. Trim the child's fingernails short C. Have the child take a tub bath daily D. Repeat treatment in 4 weeks

Trim the child's fingernails short

A nurse is assisting with the care of a child who has epilepsy and just experienced a tonic-clonic seizure. Which of the following actions should the nurse take first? A. Determine what the child was doing just before the seizure B. Turn and maintain the child in a side-lying position C. Check the child from head to toe for injuries D. Give the child's guardian a simple explanation of what occurred

Turn and maintain the child in a side-lying position

A nurse is caring for a child who is receiving oxygen. Which of the following findings indicates oxygen toxicity? A. Increased blood pressure B. Hyperventilation C. Decreased PaCo2 D. Unconsciousness

Unconsciousness

A nurse is reinforcing preoperative education with an 8 year old child prior to cardiac surgery. Which of the following actions should the nurse take? A. Provide the education for the child immediately before the surgery B. Plan the teaching session to last no longer than 60 min C. Use a doll with tubes and an incision to explain the surgery D. Discuss methods to cover the scar once healing has occurred

Use a doll with tubes and an incision to explain the surgery

The nurse is preparing to administer an oral medication to an 8 month old infant. Which of the following actions should the nurse take? A. Mix the medication with 1 tsp of honey to sweeten the taste for the infant B. Use an oral syringe to place the medication alongside the infant's tongue C. Add the medication to the infant's bottle of formula D. Place the infant in a supine position to administer the medication

Use an oral syringe to place the medication alongside the infant's tongue

A nurse is reinforcing teaching with the guardian of a child who has pediculosis capitis. Which of the following instructions should the nurse include? A. Apply mayonnaise to the affected area at night B. Treat all household pets C. Use an over the counter medication containing 1% permethrin D. Discard the child's stuffed animals

Use an over the counter medication containing 1% permethrin

A nurse is reinforcing teaching with the guardians of a school-age child who has hearing loss. Which of the following techniques should the nurse recommend to facilitate communication with the child? A. Exaggerate the pronunciation of each word B. Keep hands still when speaking C. Stand away from child when speaking D. Use facial expressions when speaking

Use facial expressions when speaking

A nurse is contributing to the plan of care for an 18-month old toddler who has cerebral palsy. Which of the following interventions should the nurse include? A. Use a mobile walker for the toddler B. Discourage activities involving repetitive joint movement C. Use manual jaw control when feeding the toddler D. Discourage the use of wrist splints

Use manual jaw control when feeding the toddler

A nurse is contributing to the preoperative teaching plan for a school-aged child who is scheduled for cardiac surgery. Which of the following recommendations should the nurse make? A. Limit education sessions to 10 min B. Use simple, concrete terms when giving explanations C. Use photographs to help explain the procedure D. Schedule education session 2 days prior to the procedure

Use photographs to help explain the procedure

A nurse is collecting data from a 12 month old infant during a well child visit. Which of the following findings should the nurse report to the provider? A. heart rate 130/min B. respiratory rate 30/min C. BP 155/70 mm Hg D. temperature 37.5 C (99.5 F)

BP 155/70 mm Hg

A nurse is reinforcing dietary teaching with the parent of a child who has phenylketonuria. Which of the following foods should the nurse include the best recommendation for a low phenylalanine diet? A. Banana B. Boiled egg C. Yogurt D. Hamburger

Banana

A nurse is caring for a child with acute laryngotracheobronchitis. Which of the following manifestations should the nurse expect? A. Barking cough B. Drooling C. High fever D. Wheezing

Barking cough

A nurse is reinforcing teaching about the introduction of solid foods with the parent of an infant. Which of the following instructions should the nurse provide? A. Begin after the extrusion reflex has diminished B. Introduce solids between 2 to 3 months of age C. Wait until the infant's first tooth erupts D. Add a sweetener such as light corn syrup to bland foods

Begin after the extrusion reflex has diminished

A nurse is caring for a preschooler who has a terminal illness. The nurse should expect the preschooler to have which of the following perspectives about death? A. Believes that her own thoughts can cause death B. Has an understanding of the finality of death C. Exhibits curiosity about what happens to the body after death D. Views funeral services as unnecessary

Believes that her own thoughts can cause death

A nurse is assisting with scoliosis screenings for a group of school-age children. The nurse should place the students in which of the following positions during the screening? A. Clasping hands while arms are raised above the head B. Bending forward with back parallel to the floor C. Standing with feet shoulder-width apart D. Bending knees while placing on hips

Bending forward with back parallel to the floor

A nurse is assisting with collecting data from 12 month old infant during a well child visit. Which of the following findings should the nurse report to the provider? A. Closed anterior fontanel B. Eruption of six teeth C. Birth weight doubled D. Birth length increased by 50%

Birth weight doubled

A nurse is assisting with the care of an adolescent following a cardiac catheterization. Which of the following is the priority finding the nurse should report to the provider? A. Reports of pain 4 out of 10 on the pain scale B. Heart rate 104/min C. Distal pulse 1+ D. Bleeding noted on the dressing

Bleeding noted on the dressing

A nurse is caring for a school-age child who has acute glomerulonephritis. Which of the following findings should the nurse report to the provider? A. BUN 8 mg/dL B. Blood creatinine 1.3 mg/dL C. Blood pressure 100/74 mm Hg D. Urine output 550 mL 24 hr

Blood creatinine 1.3 mg/dL

A nurse is collecting data from an adolescent who takes insulin for the treatment of type 1 diabetes mellitus. The nurse should identify that which of the following findings indicates effective management of the client's diabetes mellitus? A. Blood glucose value before each meal of 80 mg/dL B. Blood glucose value at bedtime of 140 mg/dL C. HbA1c of 9% D. 24 hr urine glucose of 400 mg

Blood glucose value at bedtime of 140 mg/dL

A nurse is collecting data from an 18 month old toddler who has just presented to the urgent care clinic. Which of the following data should the nurse investigate further? A. Respiratory rate 25/min B. Blood pressure 120/80 C. Heart rate 110/min D. Rectal temperature 37.4 C (99.3 F)

Blood pressure 120/80

A nurse is caring for a preschooler who has nephrotic syndrome. Which of the following findings should the nurse report to the provider? A. Blood protein 5.0 g/dL B. Hgb 14.5 g/dL C. Hct 40% D. Platelet 200,000 mm3

Blood protein 5.0 g/dL

A nurse is collecting data from a 1 week old infant at a well-baby visit. The nurse should notify the provider about which of the following assessment findings? A. A flat, dark pink area between the eyes that blanches B. An area of deep blue pigmentation over the buttocks C. Blue coloring of the sclera D. A patchy, red rash with raised centers

Blue coloring of the sclera

A nurse is collecting data from a school-age child. The nurse should identify that which of the following findings is a manifestation of physical abuse? A. Multiple dental caries B. Malnutrition C. Recurrent urinary tract infections D. Bruises at various stages of healing

Bruises at various stages of healing

A nurse is reinforcing education with the parent of a toddler who has an acute vomiting illness. Which of the following interventions should the nurse include in the teaching? A. Maintain the child on bed rest in a supine position B. Brush the child's teeth after each emesis C. Keep the child NPO until the vomiting episodes stop D. Avoid carbohydrates when reintroducing solid foods

Brush the child's teeth after each emesis

A nurse is preparing to feed an infant who has a cleft lip and palate. Which of the following actions should the nurse plan to take? A. Burp the infant at least 2 to 3 times during the feeding B. Remove the nipple from the infant's mouth if swallowing becomes audible C. Stop the feeding if formula appears in the nasal cavity of the infant D. Discourage the parents from participating in the feeding prior to a surgical repair

Burp the infant at least 2 to 3 times during the feeding

A nurse on a pediatric unit is assisting with the care of a preschooler who is prescribed an IV medication. Which of the following techniques should the nurse use to assist with preparing the child for the procedure? A. Use role-play activities with the child B. Provide the child with a detailed explanation of the procedure C. Implement interactive sessions of 30 min each with the child D. Give the child identical IV supplies to play with

Use role-play activities with the child

A nurse is assisting with the care of a child who is receiving a blood transfusion. Which of the following findings indicates the child is having a hemolytic reaction? A. Chills and flank pain B. Pruritus and flushing C. Rales and cyanosis D. Bradycardia and diarrhea

chills and flank pain

A nurse is collecting data from a toddler who has gastroesophageal reflux disease (GERD). Which of the following findings should hte nurse expect? A. abdominal distension B. constipation C. chronic cough D. decreased bowel sounds

chronic cough

A nurse is collecting data from a preschooler who has HIV. Which of the following manifestations should the nurse expect? A. Generalized petechiae B. Jaundice C. Obesity D. Chronic diarrhea

chronic diarrhea

A nurse is caring for a toddler following a tonsillectomy. Which of the following is the priority finding that the nurse should report to the provider? A. Drowsiness B. Throat pain C. Continuous swelling D. Dark brown emesis

continuous swelling

A nurse is checking the fine motor development of a 4-year-old child. The nurse should expect the child to be able to perform which of the following activities? A. Tying shoelaces into a bow B. Copying a square C. Drawing a person with at least 8 parts F. Printing the letters of her name

copying a square

A nurse is caring for an adolescent who has acne and a new prescription for isotretinoin. For which of the following adverse effects should the nurse monitor? A. Hypersalivation B. Depression C. Bradycardia D. Hyperreflexia

depression

A nurse is reinforcing teaching with a group of guardians about characteristics of infants who have failure to thrive. Which of the following characteristics should the nurse include? a. intense fear of strangers b. Increased risk for childhood obesityc. c. inability to form close relationships with siblings d. developmental delays

developmental delays

A nurse is assisting with the admission of a toddler who has bacterial meningitis caused by Haemophilus influenzae type B. Which of the following isolation guidelines should the nurse plan to initiate? A. Protective environment B. Contact precautions C. Airborne precautions D. Droplet precautions

droplet precautions

A nurse in a pediatric clinic is collecting data from an infant who was recently exposed to pertussis. The nurse should recognize which of the following as a manifestation of pertussis? A. Dry cough B. Abdominal pain C. Muscle stiffness D. Swollen eyelids

dry cough

A nurse is caring for a child who has a fractured tibia and is in Buck's traction. Which of the following actions should the nurse take? A. ensure the weights are hanging freely B. allow the child to change positions frequently C. use palms of hands when handling the traction boot D. check the pin site every 8 hr

ensure the weights are hanging freely

A nurse is reinforcing teaching with the parents of a toddler who has strabismus. Which of the following treatments should the nurse plan to include in the teaching? A. corrective biconcave lenses B. laser surgery C. eye patch D. artificial tears

eye patch

A nurse is collecting data from a child who has iron deficiency anemia. Which of the following data signifies that adherence to ferrous sulfate therapy has occurred? A. occasional vomiting and nausea B. green, tarry stools C. tolerates milk D. weight gain

green, tarry stools

A. urse ks reinforcing teaching with the guardian of a child about risk factors for attention-deficit/hyperactivity disorder (ADHD). Which of the following risk factors should the nurse include? a. formula-feeding as an infant b. history of head trauma c. history of postterm birth d. child of a single guardian

history of head trauma

A nurse in a pediatric clinic is observing for an anaphylactic reaction after administering an IM antibiotic to a child 5 min ago. Which of the following manifestations should the nurse expect to observe first? A. wheezing B. angioedema C. hives D. hypotension

hives

A nurse is collecting data about a 4 year old preschooler's gross motor skills. The nurse should expect the preschooler to be able to perform which of the following activities? A. Hopping on one foot B. Skipping on alternate feet C. Jumping rope D. Roller skating

hopping on one foot

A nurse is caring for a school age child who has hypoglycemia. Which of the following manifestations should the nurse expect? A. Oliguria B. Hypotension C. Paralytic ileus D. Flushed skin

hypotension

A nurse is caring for a child who has a head injury following a motor vehicle crash. Which of the following should the nurse recognize as an early manifestation of increased intracranial pressure? A. fixed and dilated pupils B. increased irritability C. decorticate posturing D. cheyne-stokes respirations

increased irritability

A nurse is caring for a school aged child who has hemophilia A. Which of the following finding should the nurse recognize as a manifestation of this disaster? A. joint pain and stiffness B. concave fingernails C. prominent frontal bossing D. increased risk if infection

joint pain and stiffness

A nurse is collecting data from a toddler at a well-child visit. Which of the following findings should the nurse identify as a possible indication of child maltreatment? A. diaper dermatitis B. bruise on the front of the lower leg C. inflamed unilateral conjunctiva D. laceration on the side of the torso

laceration on the side of the torso

A nurse is preparing a toddler for suturing of a minor facial laceration. The nurse should place the toddler in which of the following restraints? A. mummy restraint B. jacket restraint C. elbow restraints D. wrist restraints

mummy restraint

A nurse is assisting in the care of a male client who has acute post-streptococcal glomerulonephritis (APSGN). For which of the following manifestations should the nurse monitor? A. Hypotension B. Oliguria C. Epispadias D. Chordee

oliguria

A nurse is caring for a child who is suspected to have Enterobius vermicularis. Which of the following actions should the nurse take? A. perform a tape test B. Collect stool specimen for culture C. Test the stool for occult blood D. Assist with initiating an infusion of IV fluids

perform a tape test

A nurse is assisting with the care of a school-age child who has congestive heart failure and is receiving digoxin. Which of the following manifestations should the nurse report to the provider? A. potassium 3 mEq/L B. decreased edema C. heart rate 90/min D. peripheral pulses 3+

potassium 3 mEq/L

A nurse is contributing to the plan of care for a child who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following is the priority intervention for the nurse to recommend to include in the plan? A. promote oxygen utilization B. Administer antibiotics C. encourage fluid intake D. apply a warm compress to the joints

promote oxygen utilization

A nurse is caring for a school-age child who has skeletal traction applied to the right lower leg to repair a femur fracture. Which of the following findings is the priority for the nurse to report to the provider? A. report of tingling in the right foot B. pain rating of 7 on a scale of 0 to 10 C. decrease in food intake D. increase in crusting at pin sites

report of tingling in the right foot

A nurse is auscultating heart sounds on an infant. The nurse should identify this sounds as which of the following? A. Sinus rhythm B. ventricular septal defect C. pulmonic stenosis D. atrial septal defect

sinus rhythm

A nurse is caring for a 1 year old infant who has chronic otitis media. The nurse should identify that which of the following areas is at risk for a delay in development? A. Fine motor skills B. Visual acuity C. Speech patterns D. Hand-to-eye coordination

speech patterns

A nurse is collecting data from a 3 year old preschooler. Which of the following developmental milestones should the nurse expect the preschooler to demonstrate? A. stacking 10 blocks B. Printing 1 letter C. Tying shoelaces D. Using 7-word sentences

stacking 10 blocks

A nurse is monitoring a preschooler following an abdominal CT scan with contrast dye. The nurse should identify which of the following as an indication that the preschooler experienced an allergic reaction to the contrast dye? A. jaundice B. hematuria C. urticaria D. petechiae

urticaria

A nurse is reinforcing teaching with the guardian of an infant who has Down syndrome. Which of the following instructions should the nurse include to decrease the child's risk of an upper respiratory infection? A. rinse the infant's mouth with water before feeding B. limit the infant's fluid intake C. use a cool mist vaporizer in the infant's room D. avoid applying lip balm to the infant's lips

use a cool mist vaporizer in the infant's room

A nurse in a pediatric clinic is collecting data from an infant who recently started taking digoxin. Which of the following manifestations should the nurse identify as an indication of digoxin toxicity and report to the provider? A. irritability B. diaphoresis C. vomiting D. tachycardia

vomiting

A nurse is collecting data from an infant who has severe dehydration. Which of the following findings should the nurse expect? A. capillary refill of 2 seconds B. flushed skin C. weight loss of 10% D. bulging anterior fonanel

weight loss of 10%

A nurse is reinforcing dietary teaching with the guardian of a school-age child who has celiac disease. Which of the following foods should the nurse recommend including in the child's diet? A. white rice B. whole wheat bread C. Graham crackers D. French fries

white rice

A nurse is caring for an adolescent who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following manifestations should the nurse expect? A. Abdominal pain B. Peripheral edema C. Vesicular rash D. Stomatitis

Abdominal pain

A nurse in the emergency department is assisting with the care of a child who accidentally ingested an overdose of acetaminophen. Which of the following medications should the nurse expect to administer? A. Naloxone B. Diphenhydramine C. Glucagon D. Acetylcysteine

Acetylcysteine

A nurse is caring for a 15 month old child in a clinic. Which of the following actions should the nurse take? CHART: HepB: 1 month, 2 months, 12 months Rotavirus: 2 months, 4 months, 6 months DTaP: 2 months, 4 months, 6 months Hib: 2 months, 4 months, 12 months IPV: 2 months, 4 months, 6 months MMR: 12 months Varicella: 12 months HepA: 12 months A. Administer DTaP vaccine B. Administer rotavirus vaccine C. Hold immunizations until fever subsides D. Administer hepatitis A vaccine

Administer DTaP vaccine

A nurse is contributing to the plan of care for a child following a surgical procedure. Which of the following interventions should the nurse include in the plan of care? A. Administer NSAIDs for pain greater than 7 on a scale of 0 to 10 B. Administer intranasal analgesics for pain C. Administer IM analgesics for pain D. Administer IV analgesics on a schedule

Administer IV analgesics on a schedule

A nurse is caring for a toddler who has otitis media and a temperature of 39.1 C (102.4 F). Which of the following actions should the nurse take first? A. Reduce the temperature of the child's room B. Redress the child in minimal clothing C. Apply cool compress to the child's forehead D. Administer an antipyretic to the child

Administer an antipyretic to the child

A nurse is assisting with the care of a child in the postoperative period following a tonsillectomy. Which of the actions should the nurse take? A. Encourage the child to blow their nose gently B. Administer analgesic on a schedule C. Offer orange juice D. Position the child supine

Administer analgesic on a schedule

A nurse is caring for a toddler who has acute otitis media. Which of the following is the priority for the nurse to take? A. Provide emotional support to the family B. Reinforce teaching with the family on care of the child C. Provide a diversional activity for toddler D. Administer analgesics to the toddler

Administer analgesics to the toddler

A nurse is caring for a child who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following actions should the nurse take? A. Administer ibuprofen B. Limit daily fluid intake C. Apply cold compresses to painful joints D. Withhold live virus immunizations

Administer ibuprofen

A nurse is assisting with the care of a child who has paralytic poliomyelitis. Which of the following actions should the nurse take? A. Implement droplet precautions B. Administer oral analgesics prior to exercises C. Use humidified oxygen to thin secretions D. Initiate seizure precautions

Administer oral analgesics prior to exercises

A nurse is caring for a child who has cellulitis on the hand. Which of the following actions should the nurse take? A. Administer oral antibiotics to the child B. Cleanse area using Burrow solution C. Prepare the child for cryotherapy D. Apply a topical antifungal medication

Administer oral antibiotics to the child

A nurse is assisting with a sterile dressing change for an adolescent who has a partial thickness burn on the right hip. Which of the following actions should the nurse take first? A. Open the sterile dressing tray B. Administer pain medication to the client C. Assist the client into the lateral position D. Remove the previous dressing to inspect the wound

Administer pain medication to the client

A nurse is reinforcing discharge teaching for a child who has cystic fibrosis. Which of the following instructions should the nurse include? A. Provide a low-calorie, low protein diet B. Administer pancreatic enzymes with meals and snacks C. Implement a fluid restriction during times of infection D. Restrict physical activity

Administer pancreatic enzymes with meals and snacks

A nurse is preparing to administer an oral liquid medication to a 6 month old infant. Which of the following interventions should the nurse plan to perform? A. Mix the medication with a small amount of honey and spoon feed the infant B. Secretly place the medication in the infant's food before a meal C. Position the infant supine prior to administering the medication D. Administer the medication into the side of the infant's mouth

Administer the medication into the side of the infant's mouth

A nurse is preparing to administer an intramuscular injection to a 2 week old infant. Which of the following interventions should the nurse plan to perform? A. Apply EMLA cream to the planned injection site 30 minutes prior to the injection B. Administer no more than 1 mL of volume in a single site C. Administer the medication into the vastus lateralis muscle D. Aspirate to confirm the absence of blood return prior to administration

Administer the medication into the vastus lateralis muscle

A nurse on an inpatient pediatric psychiatric unit is caring for an 8 year old school aged child who has intermittent explosive disorder (IED). The child is currently having a temper tantrum. Which of the following communication techniques should the nurse use? A. Use an angry tone of voice to get the child's attention B. Adjust previously set limits to create a new situation C. Tell the child, "You are upsetting other people." D. Adopt a non-threatening posture

Adopt a non-threatening posture

A nurse is screening a group of school-age children for abuse. The nurse should identify that which of the following conditions places a child at risk for physical abuse? A. A child who has ADHD B. Recurrent otitis media C. Obesity D. Assertiveness

A child who has ADHD

A nurse has just received change-of-shift report for four children in a pediatric unit. Which of the following children should the nurse collect data from first? A. A child who is 2 days postoperative following an appendectomy and reports incisional pain B. A child who has a new diagnosis of diabetes mellitus and HbA1c level of 7.5% C. A child who has a fever and nuchal rigidity D. A child who experienced a seizure 1 hr ago and is resting

A child who has a fever and nuchal rigidity

A nurse is caring for a group of children in an acute care setting. The nurse should identify that which of the following children is at risk for impaired elimination? A. A child who has hyperglycemia B. A child who has enuresis C. A child who has hypothyroidism D. A child who has juvenile idiopathic arthritis

A child who has hyperglycemia

A nurse on a pediatric unit is assisting with the admission of 4 children from the emergency department. After receiving a verbal report from the nurse, for which of the following children should the nurse plan to initiate droplet precautions? A. A child who has Rocky Mountain spotted fever B. A child who has roseola C. A child who has molluscum contagiosum D. A child who has pertussis

A child who has pertussis

A nurse on a pediatric unit is assisting with the admission of 4 children. For which of the following children should the nurse initiate droplet precautions? A. A child who has pertussis B. A child who has roseola C. A child who has molluscum contagiosum D. A child who has Rocky Mountain spotted fever

A child who has pertussis

A nurse on the pediatric unit caring for a group of clients. Which of the following findings should be the nurse's priority? A. A child who has asthma and a pulse oximetry of 94% B. A child who has nephrotic syndrome and a 1+ protein on the urine dipstick C. A child who has sickle cell anemia and a urine specific gravity of 1.030 D. A child who has insulin-dependent diabetes mellitus and a finger-stick glucose reading of 110 mg/dL

A child who has sickle cell anemia and a urine specific gravity of 1.030

A nurse on a pediatric unit receives the laboratory results for several clients. Which of the following results should the nurse report to the provider? A. A client who has bacterial pneumonia and a WBC count of 15,800/mm3 B. A client who has chronic kidney disease and a calcium level of 8.7 mg/dL C. A client who has diabetic ketoacidosis and a blood glucose of 375 mg/dL D. A client who has leukemia and a hematocrit of 32%

A client who has diabetic ketoacidosis and a blood glucose of 375 mg/dL

A nurse is collecting data from a school-aged child who had a ventriculoperitoneal (V) shunt replacement. Which of the following findings indicates a complication of this procedure? A. Abdominal distention B. Unequal peripheral pulses C. Pinpoint pupils D. Frontal bossing

Abdominal distention

A nurse is reinforcing teaching with the parent of a child who has type 1 diabetes mellitus. The nurse is explaining how to manage the child's disorder during an illness such as a cold. Which of the following statements by the parent indicates an understanding of the teaching? A. "I'll reduce my child's food intake." B. "I'll check his blood glucose more often." C. "I'll limit his fluid intake between meals." D. "I won't administer his long-acting insulin dose."

"I'll check his blood glucose more often."

A nurse is reinforcing teaching about exercise with an adolescent client who has type 1 diabetes mellitus. Which of the following points should the nurse reinforce? A. "Before engaging in physical activity, you should inject insulin into a muscle group that you will be using during the activity." B. "You should plan to alternate days of vigourous physical exercise with days of increased rest." C. "Plan to avoid partipation in team sports." D. "You might need to decrease your routine insulin dosage before exercise."

"You might need to decrease your routine insulin dosage before exercise."

A nurse is reinforcing teaching with the parents of a toddler who has eterobiasis about management of the parasitic disease. Which of the following instructions should the nurse nurse include in the teaching? A. "You should encourage your child to take a tub bath daily." B. "You should keep your child's fingernails trimmed short." C. "You should dress your child in a 2-piece outfit at bedtime." D. "You should expect your child not to have a recurrence of this parasitic disease."

"You should keep your child's fingernails trimmed short."

A nurse is reviewing recommended immunizations with the guardian of a 2 month old infant. Which of the following statements should the nurse make? A. "Your baby can receive the varicella at 6 months of age." B. "Your baby can start the pneumococcal vaccine now." C. "Your baby should receive the flu vaccine now." D. "Your baby can start the measles, mumps, and rubella vaccine now."

"Your baby can start the pneumococcal vaccine now."

A nurse is caring for an adolescent who has sickle cell anemia. Which of the following manifestations is the result of chronic vaso-occlusive phenomena? (Select all that apply) A. Enlarged heart B. Enuresis C. Leg ulcers D. Extrahepatic chloestasis E. Retinal detachment

1. Enlarged heart 2. Enuresis 3. Leg ulcers 4. Retinal detachment

A school nurse is assisting a child who has been stung by a bee. The child's hand is swelling, and the nurse notes that the child is allergic to insect stings. Which of the following findings should the nurse expect if the child develops anaphylaxis (Select all that apply) A. Bradycardia B. Nausea C. Hypertension D. Urticaria E. Stridor

1. Nausea 2. Urticaria 3. Stridor

A nurse is reinforcing teaching with the guardians of a 4 month old infant about how to play with the infant. Which of the following play activities should the nurse suggest for a 4 month old infant? A. Show the infant a board book with large pictures B. Imitate the sounds of different farm animals for the infant C. Give the infant a large push-pull toy D. Allow the infant to splash in the bathtub

Allow the infant to splash in the bathtub

A nurse is assisting with the admission of a child who has a urinary tract infection (UTI) and a history of mylemeningocele. After the child's admission history is complete, which of the following actions should the nurse recommend? A. Attach a latex allergy alert identification band B. Initiate contact precautions C. Post signs in the clien't bathroom to strain the client's urine D. Administer folic acid with meals

Attach latex allergy alert identification band

A nurse in an urgent care clinic is collecting data from a preschooler who has indications of child maltreatment. The nurse should identify that which of the following findings is a manifestation of physical abuse? A. Multiple dental caries B. Malnutrition C. Frequent urinary tract infections D. Bruises at various stages of healing

Bruises at various stages of healing

A charge nurse is reinforcing teaching about child maltreatment with a group of newly licensed nurses. Which of the following pieces of information should the charge nurse include in the teaching? A. Preschoolers have the highest rates of maltreatment B. In single-parent families, the parent's nonbiological partner is typically the abuser of the child C. Children who were born prematurely are more likely to be maltreated D. Child maltreatment occurs equally across all socioeconomic groups

Children who were born prematurely are more likely to be maltreated

A nurse is collecting data from a child who is postoperative and received a unit of packed RBCs during a surgical procedure. Which of the following findings indicates the child is experiencing a hemolytic transfusion reaction? A. Chills and flank pain B. Pruritus and flushing C. Rales and cyanosis D. Bradycardia and diarrhea

Chills and flank pain

A nurse is caring for a 3 year old on a pediatric unit. The nurse should identify which of the following as an appropriate toy for the child? A. Jump rope B. Coloring book and crayons C. Checker game D. Jack-in-the-box

Coloring book and crayons

A nurse is reinforcing teaching with the parents of an infant who has a cleft palate. The parents ask the nurse how long they should wait before the infant should have corrective surgery. The nurse explains that the parents should wait no longer than 6 to 12 months to avoid which of the following outcomes? A. Repeated ear infections B. Nutritional deficits C. Immune system deficits D. Difficulty with language acquisition

Difficulty with language acquisition

A nurse is contributing to the preoperative teaching plan for a preschooler who is scheduled for a tonsillectomy. Which of the following interventions should the nurse plan to include? A. Encourage the preschooler to bring a favorite toy to the hospital B. Spend 30 minutes teaching the preschooler about what to expect C. Schedule the teaching session for the morning of the preschooler's procedure D. Reassure the preschooler that medicine will prevent pain after the procedure

Encourage the preschooler to bring a favorite toy to the hospital

A nurse is observing the behavior of a 2-year-old child. Which of the following actions should the nurse expect to observe when the child is in an activity room with other toddlers? A. Playing a simple game with another child B. Engaging in play near other children C. Sharing crayons with another toddler D. Jumping on 1 foot without help

Engaging in play near other children

A nurse is caring for a toddler who has gastroenteritis caused by salmonella. Which of the following actions is the priority for the nurse? A. Weigh the child B. Initiate contact precautions C. Establish a skin-care routine D. Obtain a recent food history

Initiate contact precautions

A nurse is caring for a school-aged child who has epilepsy and experiencing a tonic-clonic seizure. Which of the following actions should the nurse take? A. Obtain emergency equipment from the nurse's station B. Assist the child into a flat, supine position C. Loosen confining clothing D. Administer an oral anto-seizure medication

Loosen confining clothing

A nurse is caring for a 7 year old child who has Kawasaki disease. Which of the following interventions should the nurse perform? A. Apply warm soaks to irritated skin areas B. Monitor for signs of fluid retention C. Urge socialization with other children in the playroom D. Encourage the child to perform active range of motion exercises

Monitor for signs of fluid retention

A nurse in a provider's office is reinforcing teaching with the guardian of a preschooler who has cystic fibrosis. Which of the following instructions should the nurse reinforce? A. Ensure the preschooler takes a pancreatic enzyme 1 hour after each meal B. Provide the preschooler with a low-fat, high-fiber diet C. Monitor the preschooler for a decreased activity level D. Limit the preschooler's physical activity to 1 hour each day

Monitor the preschooler for a decreased activity level

A nurse is talking with the parent of an infant during a well-child visit. The parent states, "My 6-year-old started wetting the bed after we brought his baby sister home. He hasn't done that in over a year." The nurse should recognize that this behavior by the sibling is an indication of which of the following defense mechanisms? A. Regression B. Repression C. Rationalization D. Identification

Regression

A nurse is caring for a child who has a ruptured appendix. Which of the following positions should the nurse encourage the child to maintain? A. Supine B. Semi-Fowler's C. Sims' D. Orthopneic

Semi-Fowler's

A nurse is assisting the provider with an evaluation of gross and fine motor behaviors in a toddler. Which of the following behaviors is an expected achievement for a 3-year-old child? A. Walking backward with heel to toe B. Standing on 1 foot for several seconds C. Using scissors to cut out shapes D. Printing letters with a pencil

Standing on 1 foot for several seconds

A nurse is assisting with developing the plan of care for a 5 year old child who has a new diagnosis of type 1 diabetes mellitus. Which of the following actions should the nurse include in the plan? A. Use short explanations immediately prior to collecting a blood glucose level to explain what will happen when the finger stick occurs B. Teach the child to self-administer insulin injections after practicing on a doll first C. Use pictures of cuts that became infected to emphasize the need to assess the feet regularly for any injuries D. Arrange for the child to meet other peers to discuss concerns about the new diagnosis

Use short explanations immediately prior to collecting a blood glucose level to explain what will happen when the finger stick occurs

A nurse is planning care for a school-aged child who has sickle cell anemia and is experiencing a vaso-occlusive episode. Which of the following actions should the nurse plan to take? A. Apply cool compresses to the painful areas B. Limit the intake of fluid C. Apply oxygen during times of increased pain levels D. Perform passive range-of-motions exercises

apply oxygen during times of increased pain

A nurse in a pediatric clinic is talking with the parent of a toddler who states that her child will not sit at the table and eat with the family. She asks the nurse for recommendations for "finger foods" for her child. Which of the following foods should the nurse suggest? A. Slices of ripe banana B. Popcorn C. Slices of hot dogs D. Raw carrots

slices of ripe banana

A nurse on a pediatric care unit is assisting with the care of a child who has autism spectrum disorder. Which of the following actions should the nurse take? A. Provide activities to stimulate the child's interest in the envrionment B. Make frequent eye contact when talking to the child C. Offer the child choices when scheduling planned care D. Ensure staff member visits with the child are kept short

Ensure staff member visits with the child are kept short

A nurse is preparing to collect data from an 11-month-old infant during a well-child examination. Which of the following actions should the nurse take? A. Pull the infant's pinna up and back when examining the ears B. Palpate and count the infant's radial pulse for 1 seconds C. Examine the infant's throat at the end of the examination D. Check the infant's blood pressure in both arms

Examine the infant's throat at the end of the examination

A nurse is assisting with a visual acuity screening for a school-aged child using the Snellen letter chart. Which of the following actions should the nurse take? A. Position the child 5 ft away from the letter chart B. Have the child wear his glasses during the vision screening C. Observe for pupillary constriction while shining a light into the child's eye D. Instruct the child to point in the direction the letters are facing

Have the child wear his glasses during the vision screening

A nurse is reinforcing teaching with the parent of a school-aged child who has muscular dystrophy. Which of the following instructions should the nurse reinforce? A. "Assist your child as much as possible with routine daily activities." B. "Provide your child with a decreased-calorie diet." C. "The pneumococcal vaccine is not recommended for children who have muscular dystrophy" D. "Limit your child's social interactions as the disease progresses."

"Provide your child with a decreased-calorie diet."

A nurse is reinforcing teaching with the guardians of an infant who has mild gastroesophageal reflux (GER). Which of the following instructions about feeding therapies should the nurse recommend? A. "Apply the infant's diaper snugly prior to feedings." B. "Administer nasogastric feedings." C. "Thicken feedings with rice cereal." D. "Place the infant in a lateral position for 1 hour after feedings."

"Thicken feedings with rice cereal."

A nurse is reinforcing teaching with the guardian of a child who has severe iron-deficiency anemia and a new prescription for ferrous sulfate oral suspension. Which of the following statements by the guardian indicates an understanding of the instructions? A. "I should administer the medication to my child once daily in the morning." B. "Giving my child's medication with orange juice will decrease its effectiveness." C. "I should always administer to my child with a large glass of whole milk." D. "My child's blood count will be monitored regularly for the next several weeks."

"My child's blood count will be monitored regularly for the next several weeks."

A nurse is caring for a school-aged child who has terminal cancer and is receiving palliative care. The child's family asks about possible interventions. Which of the following statements should the nurse include in the teaching? A. "Nonpharmacological interventions have a place in managing your child's palliative care." B. "Palliative chemotherapy is meant to lengthen your child's life and might be curative." C. "We should limit the amount of opioids you child uses to prevent addiction." D. "It is best for your child to receive medications via intramuscular injection."

"Nonpharmacological interventions have a place in managing your child's palliative care."

A nurse is reinforcing teaching with a guardian of a child who has scarlet fever. Which of the following pieces of information should the nurse reinforce? A. "You should have your other children vaccinated to protect them from this illness." B. "The presence of Koplik spots in your child's mouth confirms scarlet fever." C. "Provide a soft or liquid diet for your child until the pain in your child's throat improves." D. "The lesions on your child's body will crust over and then begin to heal."

"Provide a soft or liquid diet for your child until the pain in your child's throat improves."

A nurse is reinforcing teaching with the guardian of an adolescent. The guardian reports that the adolescent sleeps for about 10 hours on weekend night. Which of the following responses should the nurse make? A. "Your child should have a blood test to check for anemia." B. "Adolescents need more sleep due to rapid growth." C. "Your child should not be staying up so late at night." D. "If your child is eating properly, this should not happen."

"Adolescents need more sleep due to rapid growth."

A nurse is reinforcing teaching with a 17-year-old client about managing manifestations of polycystic ovary syndrome (PCOS). Which of the following client statements indicates an understanding of the teaching? A. "Eating more lean meats and vegetables can help me lose weight." B. "I should try to get at least 11 hours of sleep each night and take a nap during the day if I feel tired." C. "I will avoid using tampons for the next 6 months to help reduce my discomfort and decrease my risk of complications." D. "I understand there are currently no medications to treat my symptoms."

"Eating more lean meats and vegetables can help me lose weight."

A nurse is preparing for the insertion of an intravenous peripheral catheter into an 8 year old child. Which of the following interventions should the nurse plan to take? A. Cover the insertion site with a firmly fastened opaque dressing B. Immobilize the extremity with a padded board after the insertion of the catheter C. Choose an 18 or 20 gauge catheter for insertion D. Apply an anesthetic cream to the intended site 60 minutes prior to the procedure

Apply an anesthetic cream to the intended site 60 minutes prior to the procedure

A nurse is assisting with the care of a school-aged child who had a tonsillectomy. Which of the following interventions should the nurse take? A. Suction secretions from the oropharynx every 2 hours B. Avoid providing straws for use when drinking fluids C. Reinforce teaching for the parent to notify the provider if brown blood is noted in emesis D. Encourage the child to blow their nose to remove excess secretions

Avoid providing straws for use when drinking fluids

A nurse is collecting data about the fine motor skills of a 3 year old preschooler. Which of the following findings should the nurse expect? A. The preschooler can draw a stick figure that has 7 parts B. The preschooler can print her first name C. The preschooler can cut out a picture using scissors D. The preschooler builds a tower of 9 cubes

The preschooler builds a tower of 9 cubes

A nurse is observing a 6-month-old infant during a well-child visit. Which of the following motor activities should the nurse expect the infant to have achieved A. Sitting alone B. Attempting to stack objects C. Picking up small objects with a crude pincer grasp D. Turning from back to stomach

Turning from back to stomach

A nurse is caring for a female adolescent who is being treated for frequent urinary tract infections (UTIs). Which of the following statements by the client indicates a possible cause of the UTIs? A. "I have bowel movements every 4 to 5 days." B. "My mom taught me to wipe from front to back after going to the bathroom." C. "I urinate every 2 to 3 hours during the day." D. "I don't wear nylon underwear."

"I have bowel movements every 4 to 5 days."

A nurse is reinforcing teaching with a 13-year-old client who has type 1 diabetes mellitus. Which of the following client statements indicates an understanding of diabetes mellitus management? A. "I will need to avoid snacks between meals." B. "I should check my blood glucose levels more often when I am sick." C. "I will need to limit my exercise to 1 hour per day." D. "I should consume 30 g of simple carbohydrate if I feel shaky."

"I should check my blood glucose levels more often when I am sick."

A nurse is reinforcing teaching with an adolescent about managing asthma and using a peak expiratory flow meter. Which of the following statements by the client demonstrates an understanding of the teaching? A. "I will use my peak flow meter whenever I feel short of breath." B. "I will continue to take my medication when my peak flow rate is in the green zone." C. "I need to use the average of 3 readings when I measure my flow rate." D. "My asthma is being controlled if my flow rate is in the yellow zone."

"I will continue to take my medication when my peak flow rate is in the green zone."

A nurse is reinforcing teaching with the parent of an infant who has talipes disorder and a new prescription for casts. Which of the following pieces of information should the nurse reinforce? A. "The casts will need to be changed once each month so your child's legs can grow as expected." B. "After the final casts are removed, no further treatment is needed to correct this disorder." C. "If casts do not correct your child's malformation, surgical correction might be necessary." D. "The casts that are used to correct this deformity decrease the risk of circulation problems."

"If casts do not correct your child's malformation, surgical correction might be necessary.

A nurse is reinforcing teaching about immunization schedules with the parents of a newborn who is 1 week old. Which of the following pieces of information should the nurse include in the teaching? A. "Initial vaccines should be administered between birth and 2 weeks of age." B. "your child will need to begin the vaccination again if subsequent doses in the series are missed." C. "An allergic reaction to a vaccine is due to the active ingredient in the vaccine." D. "A vaccination should be postponed if your child has a rectal temperature of 99.5 F and head congestion."

"Initial vaccines should be administered between birth and 2 weeks of age."

A nurse is caring for an infant who has tetralogy of Fallot and is experiencing a hypercyanotic spell while crying. Which of the following actions should the nurse take? A. Administer oxygen at 2 L via nasal cannula B. Position the infant in a knee-chest position C. Insert an intravenous catheter D. Instruct the parent to feed the child

Position the infant in a knee-chest position

A nurse is reviewing the morning laboratory results of an infant who is receiving digoxin and furosemide for the treatment of heart failure. Which of the findings should the nurse report to the provider? A. Sodium 140 mEq/L B. Calcium 10.2 mg/dL C. Chloride 100 mEq/L D. Potassium 3.2 mEq/L

Potassium 3.2 mEq/L

A nurse is caring for a child who has a tracheostomy. Which of the following techniques should the nurse use to suction the child's tracheostomy? A. Insert the catheter to 2 cm (0.79 in) beyond the end of the tracheostomy tube B. Remove the catheter while applying intermittent suction C. Instill 0.9% sodium chloride irrigation to loosen secretions while suctioning D. Continue suctioning until the secretions are removed

Remove the catheter while applying intermittent suction

A nurse is collecting data from a 24-month-old child at a well-child visit. Which of the following growth milestones should the nurse expect? A. The child can jump down from a chair independently B. The child walks upstairs alone using each foot after the other on each step C. When given a pencil, the child can make simple lines or strokes for crosses D. The child brings utensils to the mouth without rotating the hand

The child brings utensils to the mouth without rotating the hand

A nurse is collecting developmental data on a 4-year-old child. Which of the following findings should the nurse expect? A. The child is able to hop on 1 foot. B. The child is able to build a tower of up to 6 blocks C. The child is able to name the days of the week D. The child is able to identify left and right

The child is able to hop on 1 foot.

A nurse is assisting with evaluating the outcome of surgery for an infant who had a bile duct obstruction. Which of the following findings should indicate to the nurse that the surgery was successful? A. The infant's stool becomes fatty B. The color of the infant's stool is yellowish-brown C. The infant's direct bilirubin level has increased D. A palpable mass is noted in the infant's right upper quadrant

The color of the infant's stool is yellowish-brown

Results of enzyme-linked immunosorbent assay (ELISA) testing for an 18 month old infant who has Pneumocystic carinii pneumonia indicate that she is HIV-positive. When assisting with planning care, the nurse should consider which of the following factors? A. The infant's mother is likely HIV-positive B. The infant's ELISA test result is probably a false positive for HIV C. Antiretroviral medications are inappropriate for infants anf children who have HIV D. HIV-positive status is a contraindication for measles, mumps, and rubella immunizations

The infant's mother is likely HIV-positive

A nurse is reinforcing teaching with a school-aged child who has just had a fiberglass cast application following a lower-extremity fracture. Which of the following instructions should the nurse reinforce with the child and his parents about care during the first 48 hours? A. "Use a toothbrush to scratch under the case if your skin itches." B. "Avoid moving your leg and the joints above and below the cast." C. "Keep the cast above the level of your heart." D. "Clean soil from the case with soapy water."

"Keep the cast above the level of your heart."

A nurse is providing teaching about home care to the parent of a child who has a newly applied fiberglass leg cast. Which of the following statements should the nurse include? A. "Monitor the color of your child's toes every 4 hours for 24 hours." B. "Your child can scratch the skin inside the case with a small wooden ruler." C. "Expect the cast to remain damp for 72 hours." D. "You can take your child swimming and give baths as usual."

"Monitor the color of your child's toes every 4 hours for 24 hours."

A nurse is reinforcing teaching with the parents of a child who has rheumatic fever. Which of the following statements by a parent indicates an understanding of the teaching? A. "My child may take aspirin for his joint pain." B. "My child will need a blood transfusion prior to discharge." C. "I will need to wear a gown when in my child's room." D. "I will apply lotion to my child's peeling hands."

"My child may take aspirin for his joint pain."

A nurse is planning care for a preschool-aged child who has autism and is being admitted to the facility. Which of the following actions should the nurse plan to take? A. Encourage the parents to bring the child's stuffed animal B. Give the child choices when planning daily activities C. Administer phenytoin 3 times per day D. Provide a shared room with another child his age

Encourage the parents to bring the child's stuffed animal

A nurse is assisting the provider with a preschooler's annual exam. The parent expresses concern about the child's 1.8 kg (4 lb) weight gain over the past year. Which of the following responses should the nurse make? A. "This amount of weight gain could likely indicate a serious problem." B. "This weight change seems to be the result of poor eating habits." C. "Your child should have gained double this amount in a year." D. "Your child's weight change is expected for this age group."

"Your child's weight change is expected for this age group."

A nurse is reinforcing teaching with the parent of a toddler who is hospitalized and has varicella. Which of the following points should the nurse reinforce? A. "You will need to wear a surgical mask when you are in the room." B. "Your toddler will be unable to leave the room unless absolutely necessary." C. "The door to your toddler's room can remain open." D. "Isolation precautions will need to begin once the vesicles start to drain."

"Your toddler will be unable to leave the room unless absolutely necessary."

A nurse is caring for an adolescent who has end stage renal disease and is scheduled for peritoneal dialysis. Which of the following actions should the nurse take? A. Position the adolescent supine during the procedure B. Have the adolescent drink 240 mL (8 oz) of fluid prior to the procedure C. Obtain the adolescent's weight prior to the procedure D. Monitor the adolescent's vital signs every 4 hours during the procedure

Obtain the adolescent's weight prior to the procedure

A nurse is contributing to the plan of care for a preschooled-aged child who has Wilms tumor. Which of the following items should the nurse include of care prior to surgery? A. Strain the child's urine B. Monitor for postural hypotension prior to allowing the child to ambulate C. Log-roll the child when repositioning D. Place a sign above the bed that states "Do not palpate abdomen."

Place a sign above the bed that states "Do not palpate abdomen."