ATI Pediatrics Practice

A nurse in an emergency department is caring for an adolescent who has severe abdominal pain due to appendicitis. Which of the following locations should the nurse identify as McBurney's point? a. RLQ b. LLQ c. RUQ

A. The nurse should identify this area of the client's abdomen as McBurney's point. This area of the right lower quadrant located about two-thirds of the way between the umbilicus and the client's anterosuperior iliac spine is the area where a client who has appendicitis is most likely to report pain and tenderness.

A nurse is admitting an infant who has intussusception. Which of the following findings should the nurse expect? (Select all that apply.) a. Steatorrhea b. Vomiting c. Lethargy d. Constipation e. Weight gain

B, C The nurse should expect an infant who has intussusception to exhibit vomiting due to the obstruction that occurs when a segment of the bowel telescopes within another segment of the bowel. Lethargy is correct. The nurse should expect an infant who has intussusception to exhibit lethargy due to episodes of severe pain during which the infant cries inconsolably, leading to exhaustion and decreased nutritional intake.

A nurse is admitting a 4-month-old infant who has heart failure. Which of the following findings is the nurses priority? Temperature 37.5° C (99.5° F) Heart rate 70/min Respiratory rate 30/min Birth weight 3.2 kg (7 lb) Current weight 5.9 (13 lb) 3 episodes of vomiting 6 wet diapers in 24 hr Consumed 3 oz concentrated formula every 3 hr Digoxin 0.5 mcg PO Q12H & Furosemide 20 mg PO Q12H

Episodes of vomiting When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is three episodes of vomiting. This can indicate digoxin toxicity, which requires immediate intervention. Therefore, this is the nurse's priority finding.

A nurse is providing teaching to the parent of a school-age child who has a new prescription for oral nystatin for the treatment of oral candidiasis. Which of the following instructions should the nurse include? a. "Shake the medication prior to administration." b. "Provide the medication through a straw." c. "Rinse the child's mouth with water immediately after giving the medication." d. "Mix the medication with applesauce if the child dislikes the taste."

"Shake the medication prior to administration." The nurse should instruct the parent to shake the medication prior to administration to disperse the medication evenly within the suspension. The nurse should instruct the parent to put the medication directly in the child's mouth and make sure the child swishes it around before swallowing. The nurse should instruct the parent to have the child keep the medication in their mouth for as long as possible before swallowing it. Rinsing the mouth can wash some of the medication away and decrease its effectiveness. The parent should not mix the medication with food because this will interfere with the absorption.

A nurse is caring for a preschooler whose father is going home for a few hours while another relative stays with the child. Which of the following statements should the nurse make to explain to the child when their father will return? a. "Your daddy will be back at 7 p.m." b. "Your daddy will be back after he takes care of your brother." c. "Your daddy will be back in the morning." d. "Your daddy will be back after you eat."

"Your daddy will be back after you eat." Preschoolers make sense of time best when they can associate it with an expected daily routine, such as meals and bedtime. Therefore, the child comprehends time best when it is explained to them in relation to an event they are familiar with, such as eating.

A school nurse is preparing to administer atomoxetine 1.2 mg/kg/day PO to a school aged child who weights 75 lbs. Available is atomoxetine 40 mg/capsule. How many capsules should the nurse administer per day?

1 capsule

A nurse is preparing to administer ibuprofen 5 mg/kg every 6 hr PRN for a temperatures above 38.0 C (100.5 F) to an infant who weighs 17.6 lb. Available is ibuprofen oral suspension 100mg/5mL. How many mL should the nurse administer to the infant per dose?

2 mL

A nurse in an emergency department is assessing a toddler who has Kawasaki disease. Which of the following findings should the nurse expect? (Select all that apply.) a. Increased temperature b. Gingival hyperplasia c. Xerophthalmia d. Bradycardia e. Cervical lymphadenopathy

A, C, E Kawasaki disease is an acute illness associated with a fever that is unresponsive to antipyretics or antibiotics. Children who have Kawasaki disease develop a strawberry tongue, cracked lips, and edema of the oral mucosa & pharynx. A child who is receiving phenytoin therapy can develop gingival hyperplasia. Ophthalmic manifestations of Kawasaki disease include reddening of the conjunctiva and dryness of the eyes, or xerophthalmia. Kawasaki disease is an infection that affects the vascular system, including the heart. The nurse should expect the child to be tachycardic with a gallop rhythm. Long-term effects of Kawasaki disease include the development of coronary artery aneurysms or MI. A child who has Kawasaki disease can develop enlarged cervical nodes on one side of the neck that are nontender and greater than 1.5 cm in size.

A nurse is caring for a toddler who has spastic (pyramidal) cerebral palsy. Which of the following findings should the nurse expect? (Select all that apply.) a. Negative Babinski reflex b. Ankle clonus c. Exaggerated stretch reflexes d. Uncontrollable movements of the face e. Contractures

B, C, E The nurse should expect a child who has spastic cerebral palsy to exhibit ankle clonus (rhythmic reflex tremor when the foot is dorsiflexed), spasticity or exaggerated stretch reflexes, & contractures due to the tightening of the muscles. The nurse should expect a child who has nonspastic (dyskinetic) cerebral palsy, rather than spastic (pyramidal) cerebral palsy to exhibit uncontrollable movements of the face and extremities. The nurse should expect a child who has spastic cerebral palsy to exhibit a positive Babinski reflex.

The nurse is caring for a preschooler who has been receiving IV fluids via a peripheral IV catheter. When preparing to discontinue the IV fluids and catheter, which of the following actions should the nurse plan to take? a. Apply pressure over the catheter insertion site. b. Remove the tape securing the catheter c. Turn off the IV pump d. Occlude the IV tubing

C, D, B, A Turn off the IV pump Occlude the IV tubing Remove the tape securing the catheter Apply pressure over the catheter insertion site.

A school nurse is assessing an adolescent who has multiple burns in various stages of healing. Which of the following behaviors should the nurse identify as a possible indication of physical abuse? a. Expresses a reluctance to leave home b. Provides a detailed description of how the burns occurred c. Denies discomfort during assessment of injuries d. Describes strong relationships with peers

Denies discomfort during assessment of injuries. The nurse should suspect child maltreatment in the form of physical abuse if the adolescent has a blunted response to painful stimuli or injury, expresses a reluctance to return home or demonstrates a fear of parents, description of the injury is vague and inconsistent with the actual wounds, OR has withdrawn behavior and poor relationships with peers.

A nurse is assessing an adolescent who received a sodium polystyrene sulfonate enema. Which of the following findings indicates effectiveness of the medication?

Serum potassium level 4.1 mEq/L The nurse should monitor the adolescent's serum potassium level following the administration of sodium polystyrene sulfonate. This medication is used to treat hyperkalemia by exchanging sodium ions for potassium ions in the intestine. Therefore, a potassium level within the expected reference range of 3.4 to 4.7 mEq/L indicates the effectiveness of the medication.

A charge nurse in an emergency department is preparing an in-service for a group of newly licensed nurses on the clinical manifestations of child maltreatment. Which of the following manifestations should the charge nurse include as suggestive of potential physical abuse? a. Recurrent urinary tract infections b. Symmetric burns of the lower extremities c. Failure to thrive d. Lack of subcutaneous fat

Symmetric burns of the lower extremities The nurse should include that symmetric burns to the lower extremities can indicate physical abuse. The patterns are usually characteristic of the method or object used, such as cigar or cigarette burns, or burns in the shape of an iron. Recurrent UTIs are a clinical manifestation that can indicate sexual abuse. Failure to thrive can be an indication of physical neglect due to malnutrition. Lack of subcutaneous fat can be an indication of physical neglect. This manifestation can be a result of poor health care, infections that were untreated, and/or a lack of or delayed childhood immunizations.

A nurse is teaching the guardian of a 6-month-old infant about car seat use. Which of the following statements by the guardian indicates an understanding of the teaching? a. "I should secure the car seat using lower anchors and tethers instead of the seat belt." b. "I should position the car seat harness 1 inch above my baby's shoulders." c. "I will make sure that the car seat is placed at a 90-degree angle." d. "I will pad my baby's car seat with a blanket for traveling long distances."

a. "I should secure the car seat using lower anchors and tethers instead of the seat belt." Lower anchors and tethers, or the LATCH child safety seat system, should be used to secure an infant's car seat in the vehicle. This system provides anchors between the front cushion and the back rest for the car seat. Therefore, if this system is available, the seat belt does not have to be used. The car seat harness in rear-facing car seats should be positioned at or just below the infant's shoulders. The car seat should be positioned at a 45° angle to prevent slumping and injury to the infant. Padding placed underneath the infant or anywhere in the car seat can compress and/or create space between the infant and the harness. This can increase the risk for injury to the infant and should be avoided.

A nurse is teaching a group of parents about infectious mononucleosis. Which of the following statements by parent indicates an understanding the teaching? a. "Mononucleosis is caused by an infection with the Epstein-Barr virus." b. "Mononucleosis is a bacterial infection requiring 14 days of antibiotics." c. "A Monospot is a throat culture used to diagnosis mononucleosis." d. "Children who get mononucleosis will need to refrain from sports for 6 months."

a. "Mononucleosis is caused by an infection with the Epstein-Barr virus." The nurse should identify that mononucleosis is a mildly contagious illness that occurs sporadically or in groups, and is primarily caused by the Epstein-Barr virus. No known specific treatment is available for mononucleosis. Monospot is a blood test that uses a special piece of paper to assist in diagnosing mononucleosis. A child who has mononucleosis should adjust their activities according to their level of fatigue. It is recommended that contact sports be avoided for about 4 weeks, or until splenomegaly has resolved.

A nurse is caring for a 15 year-old client who is married and is scheduled for a surgical procedure. The client asks, "who should sign my surgical consent?" Which of the following responses should the nurse make? a. "You can sign the consent form because you are married." b. "Your spouse should sign the consent form for you." c. "Your parent should sign the consent form for you." d. "You can appoint a legal guardian to sign the consent form."

a. "You can sign the consent form because you are married." The nurse should inform the adolescent that marriage gives adolescents the legal right to consent to surgical procedures and sign other legal documents that they would not otherwise be able to sign due to their age. Adolescents who are married can sign the consent form and do not require the consent of their spouse.

A nurse is providing dietary teaching to the guardian of a school-age child who has cystic fibrosis. Which of the following statements should the nurse make? a. "You should offer your child high-protein meals and snacks throughout the day." b. "You should decrease your child's dietary fat intake to less than 10% of their caloric intake." c. "You should restrict your child's calorie intake to 1,200 per day." d. "You should give your child a multivitamin once weekly."

a. "You should offer your child high-protein meals and snacks throughout the day." The nurse should instruct the guardian to provide a diet that is well-balanced & high in protein & calories (at least 2,000 cal/day. Children who have CF require a higher percentage of the recommended dietary allowances of all nutrients to meet their energy requirements. Children who have good nutritional intake have improved lung function & decreased risk of infection. Children who have CF need a diet that is unrestricted in fat. They also require 35-40% of their calories to come from fats due to decreased absorption from the intestines.

A nurse is teaching the guardian of a 6-month-old infant about teething. Which of the following statements should the nurse make? a. "Your baby might pull at their ears when they are teething." b. "Rub your baby's gums with an aspirin to decrease discomfort." c. "Place a beaded teething necklace around your baby's neck." d. "Your baby's upper middle teeth will erupt first."

a. "Your baby might pull at their ears when they are teething." The nurse should inform the guardian that teething can result in discomfort for the infant. Therefore, the guardian should look for indications such as pulling on the ears, difficulty sleeping, increased drooling, or increased fussiness. The guardian should avoid using aspirin or teething powders due to the risk of aspiration, infection, or irritation of the gum tissues. The nurse should recommend cold teething rings or gently rubbing the infant's gums with a cold cloth to minimize discomfort. Necklaces can result in suffocation and choking. The nurse should inform the guardian that the eruption of an infant's teeth begins with the lower central incisors.

A nurse is receiving change-of-shift report on four children. Which of the following children should the nurse see first? a. A school-age child who has sickle cell anemia and reports decreased vision in the left eye b. A school-age child who has cystic fibrosis and a frequent nonproductive cough c. A preschooler who has asthma and a peak flow meter reading in the green zone d. An adolescent who has meningitis and reports a sensitivity to lights and noise

a. A school-age child who has sickle cell anemia and reports decreased vision in the left eye. When using the urgent vs. nonurgent approach to client care, the nurse should determine the priority finding is a report of decreased vision in the left eye. This finding indicates that the child is experiencing a vaso-occlusive crisis and should be reported to the provider immediately. Therefore, the nurse should see this child first. The others are nonurgent and expected.

A nurse is receiving change-of-shift report for four children. Which of the following children should the nurse assess first? a. A toddler who has a concussion and an episode of forceful vomiting b. An adolescent who has infective endocarditis and reports having a headache c. An adolescent who was placed into halo traction 1 hr ago and reports pain as 6 on a scale of 0 to 10 d. A school-age child who has acute glomerulonephritis and brown-colored urine

a. A toddler who has a concussion and an episode of forceful vomiting. When using the urgent vs. nonurgent approach to client care, the nurse should assess this child first. An episode of forceful vomiting is an indication of increased intracranial pressure in a toddler who has a concussion.

A nurse is creating a plan of care for a preschooler who has Wilms' tumor and is scheduled for surgery. Which of the following interventions should the nurse include? a. Avoid palpating the abdomen when bathing the child before surgery. b. Refrain from auscultating the child's bowel sounds during the postoperative assessment. c. Encourage the child to play with other children on the unit prior to surgery. d. Explain to the child that their pain will be managed after the surgery.

a. Avoid palpating the abdomen when bathing the child before surgery. The nurse should avoid palpating the abdomen when bathing the child before surgery because movement of the tumor can cause cancer cells to disseminate to other sites, adjacent & distant to the tumor site. Auscultation of the child's bowel sounds to monitor for an obstruction is an important part of the postoperative assessment. The child's risk for injury increases with physical activity. Therefore, the nurse should not encourage the child to play with other children on the unit. Telling the child about pain prior to surgery will likely increase their fear and anxiety level

A nurse is caring for a school-age child who has primary nephrotic syndrome and is taking prednisone. Following 1 week of treatment, which of the following manifestations indicates to the nurse that the medication is effective? a. Decreased edema b. Increased abdominal girth c. Decreased appetite d. Increased protein in the urine

a. Decreased edema A child who has nephrotic syndrome can experience edema due to the increased glomerular permeability, which increases protein loss. Prednisone decreases glomerular permeability, which causes fluid to shift from the extracellular spaces, resulting in decreased edema.

A nurse is caring for a school-age child who has diabetes mellitus and was admitted with a diagnosis of diabetic ketoacidosis. When performing the respiratory assessment, which of the following findings should the nurse expect? a. Deep respirations of 32/min b. Shallow respirations of 10/min c. Paradoxic respirations of 26/min d. Periods of apnea lasting for 20 seconds

a. Deep respirations of 32/min The nurse should expect Kussmaul respirations in a child who has diabetic ketoacidosis. These deep and rapid respirations are the body's attempt to eliminate excess carbon dioxide and achieve a state of homeostasis.

A nurse is reviewing the laboratory results of a school-age child who is 1 week postoperative following an open fracture repair. Which of the following findings should the nurse identify as an indication of a potential complication? a. Erythrocyte sedimentation rate 18 mm/hr b. WBC count 6,200/mm3 c. C-reactive protein 1.4 mg/L d. RBC count 4.7 million/mm3

a. Erythrocyte sedimentation rate 18 mm/hr The nurse should identify that an ESR of 18 mm/hr is above the expected reference range of up to 10 mm/hr & is an indication of osteomyelitis. Normal findings: WBC = 5,000-10,000/mm3 CRP < 10.0 mg/L RBC = 4-5.5 million/mm3

A nurse is assessing the pain level of a 3-year-old toddler. Which of the following pain assessment scales should the nurse use? a. FACES b. Numeric c. CRIES d. Visual analog

a. FACES The nurse should use the FACES pain rating scale for pediatric clients who are 3 and older. This scale allows the toddler to point to the face that depicts their current level of pain. The nurse can then determine the need for pain management.

A nurse is caring for an infant who has respiratory syncytial virus (RSV). Which of the following actions should the nurse implement for infection control? a. Have a designated stethoscope in the infant's room. b. Place the infant in a room equipped with negative airflow. c. Administer palivizumab as prescribed for the infant. d. Remove gloves after leaving the infant's room.

a. Have a designated stethoscope in the infant's room. The nurse should initiate droplet precautions for an infant who has RSV because the virus is spread by direct contact with respiratory secretions. Therefore, designated equipment, such as a blood pressure cuff and a stethoscope, should be placed in the infant's room. A room equipped with negative airflow is not necessary and is only initiated for infants who need airborne precautions. Palivizumab is used for prophylaxis in at-risk infants and is not used in the treatment of RSV. To reduce the risk of transmission, all health care personnel should remove their gloves prior to leaving the infant's room.

A nurse in a health department is caring for an emancipated adolescent who has an STI and is unaccompanied by a guardian. Which of the following actions should the nurse take? a. Have the adolescent sign a consent form for treatment. b. Instruct the adolescent to return with a guardian. c. Obtain consent from the adolescent's guardian over the phone. d. Treat the adolescent without a consent form.

a. Have the adolescent sign a consent form for treatment. The nurse should identify that an emancipated minor can sign the consent form for treatment of an STI or any other form of medical treatment requiring consent.

A nurse is reviewing the laboratory report of a school-age child who is experiencing fatigue. Which of the following findings should the nurse recognize as an indication of anemia? a. Hematocrit 28% b. Hemoglobin 13.5 g/dL c. WBC count 8,000/mm3 d. Platelets 250,000/mm3

a. Hematocrit 28% The nurse should recognize that this hematocrit level is below the expected reference range of 32% to 44% for a school-age child. The child can exhibit fatigue, lightheadedness, tachycardia, dyspnea, & pallor due to the decreased oxygen-carrying capacity. Hct = 32% - 44% Hgb = 9.5 - 14 g/dL WBC = 5,000 - 10,000/mm3 150,000 - 400,000/mm3

A nurse is reviewing the laboratory report of a 7 year-old child who is receiving chemotherapy. Which of the following lab values should the nurse report to the provider? a. Hgb 8.5 g/dL b. WBC count 9,500/mm3 c. Prealbumin 18 mg/dL d. Platelets 300,000/mm3

a. Hgb 8.5 g/dL A child receiving chemotherapy is at risk for anemia due to the chemotherapy effects on the blood-forming cells of the bone marrow. The nurse should recognize that a Hgb level of 8.5 g/dL is below the expected reference range for a 7-year-old child and should be reported to the provider. Hgb = 10 - 15.5 g/dL WBC = 5,000 - 10,000/mm3 Prealbumin = 15 - 33 mg/dL Plt = 150,000 - 400,000/mm3

A nurse is assessing an infant who has a ventricular septal defect. Which of the following findings should the nurse expect? a. Loud, harsh murmur b. Dysrhythmias c. Weak femoral pulses d. High blood pressure

a. Loud, harsh murmur The nurse should expect to hear a loud, harsh murmur with a ventricular septal defect due to the left-to-right shunting of blood, which contributes to hypertrophy of the infant's heart muscle. Ventricular septal defect does not affect the electrical conduction of the heart. Therefore, the nurse should not expect to hear dysrhythmias when assessing this infant. The nurse should expect weak femoral pulses & an elevated BP when assessing an infant who has coarctation of the aorta.

A nurse is assessing an infant who has pneumonia. Which of the following findings is the priority for the nurse to report to the provider? a. Nasal flaring b. WBC count 11,300/mm3 c. Diarrhea d. Abdominal distension

a. Nasal flaring When using the airway, breathing, & circulation approach to client care, the nurse should determine that the priority finding to report to the provider is nasal flaring. Nasal flaring indicates the infant is experiencing ARD. Diarrhea & abdominal distension are manifestations of pneumonia in infants & indicates the current treatment is not effective, but not priority. WBC range is normal.

A nurse is caring for a school-age child who has peripheral edema. The nurse should identify that which of the following assessments should be performed to confirm peripheral edema? a. Palpate the dorsum of the child's feet. b. Weigh the child daily using the same scale. c. Assess the child's skin turgor. d. Observe the child for periorbital swelling.

a. Palpate the dorsum of the child's feet The nurse should palpate the dorsum of the feet by pressing the fingertip against a bony prominence for 5 seconds to assess for peripheral edema.

A nurse is caring for a school-age child who has experienced a tonic-clonic seizure. Which of the following actions should the nurse take during the immediate postictal period? a. Place the child in a side-lying position. b. Delay documentation until the child is fully alert. c. Give the child a high-carbohydrate snack. d. Administer an oral sedative to the child.

a. Place the child in a side-lying position. The nurse should place the child in a side-lying position to prevent aspiration.

A nurse is caring for an infant who is receiving IV fluids for the treatment of Tetralogy of Fallot and begins to have hypercryanotic spell. Which of the following actions should the nurse take? a. Place the infant in a knee-chest position. b. Administer a dose of meperidine IV. c. Discontinue administration of IV fluids. d. Apply oxygen at 2 L/min via nasal cannula.

a. Place the infant in a knee-chest position The nurse should place the infant in a knee-chest position during a hypercyanotic spell to decrease the return of desaturated venous blood from the legs and to direct more blood into the pulmonary artery by increasing systemic vascular resistance. The nurse should administer morphine IV to the infant, instead of meperidine, to decrease infundibular spasms that cause a decrease in pulmonary blood flow and right-to-left shunting. The nurse should continue the administration of IV fluids during a hypercyanotic spell to decrease the viscosity of the infant's blood, which decreases the risk of a CVA. The nurse should apply oxygen at 100% via face mask to assist with dilation of the pulmonary artery and improve oxygen supply to the brain.

A nurse is creating a plan of care for a school-age child who has heart disease and has developed heart failure. Which of the following interventions should the nurse include in the plan? a. Provide small, frequent meals for the child. b. Schedule time in the play room for the child. c. Weigh the child weekly. d. Maintain the child in a supine position.

a. Provide small, frequent meals for the child. The metabolic rate of a child who has heart failure is high because of poor cardiac function. Therefore, the nurse should provide small, frequent meals for the child because it helps to conserve energy. The nurse should restrict play activities to the child's bed to minimize energy expenditure. The nurse should weigh the child daily. To provide for maximum chest expansion, the nurse should maintain the child's bed in a semi-Fowler's position.

A nurse is planning developmental activities for a newly admitted 10-year-old child who has neutropenia. Which of the following actions should the nurse plan to take? a. Provide the child with a book about adventure. b. Arrange frequent visits from family members and peers. c. Give the child a large-piece puzzle. d. Use puppets to entertain the child.

a. Provide the child with a book about adventure. The nurse should provide a school-age child with a book about adventure as a developmental activity because children are expanding their knowledge and imagination during this age. Through reading, school-age children can feel powerful and skillful as they imagine themselves in the stories they read. Visitors should be limited for a child who has neutropenia because this places the child at an increased risk for infection. The nurse should provide a large-piece puzzle to a preschooler. School-age children tend to be challenged mentally with complex board and video games. The nurse should use puppets to entertain toddlers. School-age children are not typically entertained for very long or challenged mentally with puppets.

A nurse is planning an educational program for school-age children and their parents about bicycle safety. Which of the following information should the nurse plan to include? a. The child should be able to stand on the balls of their feet when sitting on the bike. b. The child should ride their bike 2 feet to the side of other bike riders. c. The child should wear dark-colored clothing with a fluorescent stripe when riding at night. d. The child should ride the bike facing traffic when it is necessary to ride in the street.

a. The child should be able to stand on the balls of their feet when sitting on the bike. To decrease the risk for injury, parents should ensure that the bike is the correct size for the child. When seated on the bike, the child should be able to stand with the ball of each foot touching the ground & should be able to stand with each foot flat on the ground when straddling the bike's center bar. To decrease the risk for injury, children should ride their bikes single file rather than side by side. When riding a bike at night, children should wear light-colored clothing that has fluorescent material attached. This measure, along with fluorescent material on the bike itself, makes bike riders more visible to motor vehicle drivers and other bike riders. bike riders should ride in the direction of the flow of traffic.

A nurse in an emergency department is auscultating the lungs of an adolescent who is experiencing dyspnea. The nurse should identify the whistling sound as which of the following? a. Wheezes b. Crackles c. Pleural friction rub d. Rhonchi

a. Wheezes The nurse should identify the sound during auscultation as wheezes, which are high-pitched, musical or whistling-like sounds heard primarily on expiration as air passes through and vibrates narrowed airways. Crackles occur when air expands deflated alveoli or when the passage of air through small airways is disrupted & are identified as high-pitched, short, & noncontinuous sounds usually heard at the end of inspiration. A pleural friction rub occurs when the pleurae are inflamed & the surfaces rub together & are identified as a loud, rough, grating sound that can be heard during inspiration or expiration. Rhonchi occur when the larger airways are obstructed & are identified as as low-pitched, continuous sounds that have a snore-like quality and are usually louder during expiration.

A nurse in a provider's office if preparing to administer immunizations to a toddler during a well-child visit. Which of the following actions should the nurse plan to take? Age 15 months Allergies Neomycin (anaphylactic reaction) Caregiver reports rhinitis with clear nasal drainage for 2 days Occasional nonproductive cough for 2 days History of asthma RR 24/min HR115/min Temperature 36.9° C (98.4° F) a. Withhold the measles, mumps, and rubella (MMR) vaccine. b. Withhold the diphtheria, tetanus, and pertussis (DTaP) vaccine. c. Withhold the influenza vaccine. d. Withhold the tuberculin skin test (TST).

a. Withhold the measles, mumps, and rubella (MMR) vaccine. The nurse should recognize that an allergy to neomycin with an anaphylactic reaction is a contraindication for receiving the MMR vaccine. Clients who have a severe allergy to eggs or gelatin should not receive this vaccine. It is safe to administer the DTaP vaccine at the same time as the MMR vaccine and TST. DTaP vaccines are not contraindicated for children who have mild acute illness or asthma. A child who has asthma can receive the inactivated influenza vaccine. It is safe to perform a TST at the same time as administering MMR and varicella vaccines. A TST is not contraindicated for children who have mild acute illness or asthma.

A nurse is providing teaching to the parent of an infant who has diaper dermatitis. The nurse should instruct the parent to apply which of the following to the affected area? a. Zinc oxide b. Antibiotic ointment c. Talcum powder d. Antiseptic solution

a. Zinc oxide Diaper dermatitis is a common inflammatory skin disorder caused by contact with an irritant such as urine, feces, soap, or friction, and takes the form of scaling, blisters, or papules with erythema. Providing a protective barrier, such as zinc oxide, against the irritants allows the skin to heal. Diaper dermatitis can be the result of an overgrowth of yeast, such as Candida albicans, on the skin. Treatment for yeast-related dermatitis includes a topical antifungal medication. However, antibiotic ointment is not recommended for the treatment of diaper dermatitis. Talcum powder is not recommended for the treatment of diaper dermatitis because it has been linked to respiratory disorders in infants. Infants who have diaper dermatitis should have the affected areas gently washed with water and a mild soap. Antiseptic solution is not recommended because this can cause burning and pain to the infant.

52. A nurse is teaching the parents of a toddler who has cognitive impairment about toilet training. Which of the following instructions should the nurse include in the teaching? a. "Scold your child when they have a toileting accident." b. "Award your child with a sticker when they sit on the potty chair." c. "Play your child's favorite song while teaching them to use the potty chair." d. "Teach multiple steps of the skill at the same time."

b. "Award your child with a sticker when they sit on the potty chair." A child who has a cognitive impairment learns through shaping behaviors. The parents should reward the child for sitting on the potty chair as a reinforcement of the desired behavior of continence. As the child repeats this action, the parents can gradually decrease this reward and then give rewards for the next step in the task, such as voiding while sitting on the potty chair. The parents should use positive reinforcement when teaching their child a new task. Reinforcing positive behaviors, such as remaining dry through the night, will have a greater effect on the child than the negative reinforcement of scolding. A child who has a cognitive impairment has difficulty discriminating between two or more cues or stimuli. The nurse should instruct the parents to eliminate all other stimuli when teaching the child the task of toilet training. Children who have a cognitive impairment have difficulty remembering multiple steps.

A nurse is providing teaching to the parents of a preschooler who has heart failure and a new prescription for digoxin twice daily. Which of the following instructions should the nurse include in the teaching? a. "Use a kitchen teaspoon to measure the medication." b. "Brush the child's teeth after giving the medication." c. "Double the next dose if the child misses a dose." d. "Repeat the dose if the child vomits."

b. "Brush the child's teeth after giving the medication." The nurse should teach the parent to closely monitor the child's number of wet diapers. Monitoring the number of wet diapers per day is an effective way for the parent to monitor adequate output and hydration status. The nurse should instruct the parents to use the calibrated device that comes with the medication when measuring the medication to avoid accidental overdose. The parent should administer digoxin at regular intervals, usually twice daily, or every 12 hr. The nurse should instruct the parents not to double the medication amount if they miss a dose because this can result in digoxin toxicity. Nausea, vomiting, and decreased appetite are common manifestations of digoxin toxicity in children. The nurse should instruct the parents not to administer a second dose if the child vomits and to notify the provider.

A nurse is planning n educational program to teach parents about protecting their children from sunburns. Which of the following instructions should the nurse plan to include? a. "Allow your child to play outside during the hours between 10:00 a.m. and 2:00 p.m." b. "Choose a waterproof sunscreen with a minimum SPF of 15." c. "Dress your child in loose weave polyester fabric prior to sun exposure." d. "Reapply sunscreen every 4 hours."

b. "Choose a waterproof sunscreen with a minimum SPF of 15." The nurse should instruct parents to apply a waterproof sunscreen with a minimum SPF of 15 for children. The parents should apply the sunscreen prior to sun exposure to reduce the risk of sunburn. The nurse should instruct parents to avoid allowing their children to play outside during the hours between 10:00-2:00 because the child is at greatest risk for developing a sunburn during this time. The nurse should instruct parents to dress their children in tight weave cotton fabric prior to sun exposure to protect the skin from the sun. The nurse should instruct parents to reapply sunscreen every 2-3 hr.

A nurse is providing teaching to the family of a school-age child who has juvenile idiopathic arthritis. Which if the following instructions should the nurse include in the teaching? a. "Limit movement of the child's large joints." b. "Encourage the child to perform independent self-care." c. "Provide the child with a soft mattress for sleeping." d. "Schedule a 2-hour daily nap for the child in the afternoon."

b. "Encourage the child to perform independent self-care." The nurse should teach the family the importance of encouraging the child to perform independent self-care. This will minimize the child's pain while maximizing mobility. Encouraging and praising the child's efforts for independence will also increase their self-esteem. Large joints should be exercised regularly to maintain mobility and strengthen muscles & sleep on a firm mattress to provide support in maintaining joints in a functional position. Daytime naps are discouraged because stiffness can occur quickly and easily with inactivity, and naps can interfere with nighttime sleeping.

A nurse is providing teaching to an adolescent about how to manage tinea pedis. Which of the following statements by the adolescent indicates an understanding of the teaching? a. "I should buy plastic shoes to wear at the swimming pool." b. "I should wear sandals as much as possible." c. "I should place the permethrin cream between my toes twice daily." d. "I should seal my nonwashable shoes in plastic bags for a couple of weeks."

b. "I should wear sandals as much as possible." Sandals allow air to circulate around the feet, decreasing perspiration and eliminating the medium for bacteria and fungus to grow. The nurse should inform the adolescent that wearing sandals, open-toed, or well-ventilated shoes will promote healing of the fungal infection. The use of plastic shoes increases the occurrence of tinea pedis. Permethrin 5% cream is a scabicide used to treat scabies. This treatment is not indicated for tinea pedis. Sealing nonwashable items in plastic bags for 14 days is a recommended practice for clients who have pediculosis. This practice is not indicated for tinea pedis.

A nurse is teaching a school-age child who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the child indicates an understanding of the teaching? a. "I will puncture the pad of my finger when I am testing my blood glucose." b. "I will give myself a shot of regular insulin 30 minutes before I eat breakfast." c. "I will eat a snack of 5 grams of carbohydrates if my blood glucose is low." d. "I will decrease the amount of fluids I drink when I am sick."

b. "I will give myself a shot of regular insulin 30 minutes before I eat breakfast." The child should administer regular insulin 30 min before meals so that the onset coincides with food intake. The child should avoid puncturing the pads of the fingers because they have fewer blood vessels & more nerve fibers. Instead, the child should puncture the skin on either side of the finger pad to promote blood flow &decrease pain. The child should eat a snack of 10-15 g of carbs, such as 120 mL (4 oz) of fruit juice or 66 g (1/2 cup) of ice cream, to rapidly increase the BG level during a mild hypoglycemic reaction. During acute illness, the child is prone to hyperglycemia & ketonuria and is at risk for dehydration. Therefore, the child's fluid intake should be increased, rather than decreased.

A nurse is teaching the parents of a school-age child who has a new diagnosis of osteomyelitis of the tibia. The nurse should identify that which of the following statements by the parents indicates an understanding of the teaching? a. "My child will have a cast until healing is complete." b. "My child will receive antibiotics for several weeks." c. "My child can return to playing sports once they have been discharged." d. "My child needs to be in contact isolation."

b. "My child will receive antibiotics for several weeks." The nurse should instruct the parent that the child will receive antibiotic therapy for at least 4 weeks. Surgery might be indicated if the antibiotics are not successful. Bearing weight must be avoided with osteomyelitis & it will be several weeks to months before the child can play contact sports.. Therefore, the child should be placed in a comfortable position with the limb supported. There is no indication for a cast. Contact isolation is not necessary because osteomyelitis is not a communicable illness.

The nurse is assessing a school-age child who has peritonitis. Which of the following findings should the nurse expect? a. Hyperactive bowel sounds b. Abdominal distention c. Bradycardia d. Bloody stool

b. Abdominal distension The nurse should identify that abdominal distention is an expected finding of peritonitis. Peritonitis is an inflammation of the lining of the abdominal wall. This inflammation in the abdomen, along with the ileus that develops, causes abdominal distention. Other manifestations include chills, irritability, & restlessness. Hypoactive bowel sounds are a manifestation of peritonitis. The peritoneal inflammation caused by the feces and bacteria released from the perforated appendix results in the development of an ileus and a decrease in bowel motility. Tachycardia is a manifestation of peritonitis, resulting from infection and fluid shifts within the abdomen, which causes hypovolemia. Bloody stool is a manifestation of Meckel diverticulum, not peritonitis. Diarrhea or constipation can be manifestations of appendicitis.

A nurse is assessing a school-age child immediately following a perforated appendix repair. Which of the following findings should the nurse expect? a. Purulent nasogastric drainage b. Absence of peristalsis c. Passage of dark red stool with mucus d. WBC count 6,000/mm3

b. Absence of peristalsis The nurse should expect absence of peristalsis immediately following a perforated appendix repair, until the bowel resumes functioning. Purulent drainage is not an expected finding following a perforated appendix repair. The nurse should expect brown to green-tinged drainage from the NG tube. Passage of dark red stool with mucus is not an expected finding immediately following a perforated appendix repair. The nurse should identify this finding as a manifestation of Meckel diverticulum. The nurse should expect a WBC count greater than 20,000/mm3 in a client who has had a ruptured appendix.

A nurse in an emergency department is caring for a school-age child who has sustained a minor superficial burn from fireworks on their forearm. Which of the following actions should the nurse take? a. Administer the tetanus toxoid vaccine if more than 1 year since the prior dose. b. Apply an antimicrobial ointment to the affected area. c. Leave the burn area open to air. d. Place an ice pack on the affected area.

b. Apply an antimicrobial ointment to the affected area. The nurse should apply an antimicrobial ointment to the burned area to prevent infection. The nurse should administer the tetanus toxoid vaccine if it has been more than 5 years since the prior dose. The nurse should apply a clean-dry dressing of fine mesh gauze and a light gauze dressing that restricts movement to prevent injury to the wound. Applying ice to the affected area can impair circulation to the area and increase tissue damage.

A nurse is preparing an adolescent for a lumbar puncture. Which of the following actions should the nurse take? a. Place a cardiac monitor on the adolescent prior to the procedure. b. Apply topical analgesic cream to the site 1 hr prior to the procedure. c. Keep the adolescent in a semi-Fowler's position for 4 hr following the procedure. d. Restrict fluids for 2 hr following the procedure.

b. Apply topical analgesic cream to the site 1 hr prior to the procedure. The nurse should apply a topical analgesic to the lumbar site 1 hr prior to the procedure to decrease the adolescent's pain while the lumbar needle is inserted. Cardiac monitoring is not necessary during a LP. The nurse should place the adolescent in the prone position or flat in bed for up to 12 hr following the procedure to prevent postprocedural spinal headache. The nurse should encourage the adolescent to drink extra fluids following the procedure to replace the CSF removed during the procedure.

A nurse is caring for a toddler who has acute otitis media and a temperature of 40 C (104 F). After administering acetaminophen, which of the following actions should the nurse plan to take to reduce the toddler's temperature? a. Apply a cooling blanket to the toddler. b. Dress the toddler in minimal clothing. c. Give the toddler a tepid bath. d. Administer diphenhydramine to the toddler.

b. Dress the toddler in minimal clothing. The nurse should recognize that dressing the toddler in minimal clothing will expose the skin to air & maximize heat evaporation from the skin, thus reducing the toddler's temperature. Diphenhydramine is an antihistamine indicated for the treatment of an allergic reaction. The nurse should identify that antipyretics, such as acetaminophen, are indicated for the treatment of a fever. A tepid bath is lukewarm, which can cause discomfort to the toddler. The nurse should be aware that the use of a tepid bath is indicated for the treatment of hyperthermia, but not a fever. Applying a cooling blanket can cause shivering and discomfort, which increases metabolic requirements. The nurse should be aware that the use of a cooling blanket is indicated for the treatment of hyperthermia, but not a fever.

A nurse is caring for a school-age child who is receiving cefazolin via intermittent IV bolus. The child suddenly develops diffuse flushing of the skin and angioedema. After discontinuing the medication infusion, which of the following medications should the nurse administer first? a. Prednisone b. Epinephrine c. Diphenhydramine d. Albuterol

b. Epinephrine This child is most likely experiencing an anaphylactic reaction to the cefazolin. According to evidence-based practice, the nurse should first administer epinephrine to treat the anaphylaxis. Epinephrine is a beta adrenergic agonist that stimulates the heart, causes vasoconstriction of blood vessels in the skin and mucous membranes, and triggers bronchodilation in the lungs.

A nurse is caring for a school-age child who is receiving a blood transfusion. Which of the following manifestations should alert the nurse to a possible hemolytic transfusion reaction? a. Laryngeal edema b. Flank pain c. Distended neck veins d. Muscular weakness

b. Flank pain The nurse should recognize that flank pain is caused by the breakdown of RBCs and is an indication of a hemolytic reaction to the blood transfusion. Laryngeal edema is an indication of an allergic reaction to the blood transfusion. Distended neck veins are an indication of circulatory overload, which is a complication of a blood transfusion. Muscle weakness is an indication of an electrolyte disturbance, which is a complication of a blood transfusion.

A nurse in an emergency department is caring for a school-age child who has appendicitis and rates their abdominal pain as 7 on a scale of 0 to 10. Which of the following actions should the nurse take? a. Instill a 500 mL tap water enema. b. Give morphine 0.05 mg/kg IV. c. Administer polyethylene glycol 1g/kg PO. d. Apply a heating pad to the child's abdomen.

b. Give morphine 0.05mg/kg IVA pain level of 7 on a scale of 0 to 10 is considered severe. The nurse should administer an analgesic medication for pain relief. Administering an enema or laxatives accelerate bowel motility and increases the risk for perforation of the appendix. Applying heat to the child's abdomen increases the risk for perforation of the appendix.

A nurse is monitoring the oxygen saturation level of an infant using pulse oximetry. The nurse should secure the sensor to which of the following areas on the infant? a. Wrist b. Great toe c. Index finger d. Heel

b. Great Toe. The nurse should secure the sensor to the great toe of the infant and then place a snug-fitting sock on the foot to hold the sensor in place. The nurse should also check the skin under the sensor site frequently for temperature, color, and the presence of a pulse.

A nurse is an emergency department is caring for a school-age child who has epiglottitis. Which of the following actions should the nurse take? a. Obtain a throat culture from the child. b. Monitor the child's oxygen saturation. c. Put a warm mist humidifier in the child's room. d. Place the child in the supine position.

b. Monitor the child's oxygen saturation The nurse should monitor the child's oxygen saturation level because the child is experiencing acute respiratory distress and it is necessary to determine if the child is responding to treatment. Obtaining a throat culture places the child at risk for complete airway obstruction. The nurse should wait until an airway is established for the child before performing any diagnostic testing. The nurse should administer humidified oxygen by face mask or blow-by, rather than place a warm mist humidifier in the child's room. Placing the child in the supine position increases the child's risk for complete airway obstruction. The nurse should allow the child to be in whatever position they feel provides the most help with breathing. This is usually an upright position, and sometimes it is helpful for the child to lean forward to help with breathing.

A nurse is assessing a school-age child who has meningitis. Which of the following findings is the priority for the nurse to report to the provider? a. Reports a headache as 6 on a 0 to 10 pain scale b. Petechiae on the lower extremities c. Nuchal rigidity d. Positive Kernig's sign

b. Petechiae on the lower extremities The presence of a petechial or purpuric rash on a child who is ill can indicate the presence of meningococcemia. This type of rash indicates the greatest risk of serious rapid complications from sepsis and should be reported immediately to the provider. The others are expected findings with meningitis.

A nurse is assessing a 6-month-old infant during a well-child visit. Which of the following findings should the nurse report to the provider? a. Presence of a central incisor tooth b. Presence of strabismus c. Presence of an open anterior fontanel d. Presence of external cerumen

b. Presence of strabismus Strabismus, or crossing of the eyes, typically disappears at 3 to 4 months of age. If not corrected early, this can lead to blindness. Therefore, the nurse should report this finding to the provider.

A nurse is assessing a 3-year-old toddler at a well-child visit. Which of the following manifestations should the nurse report to the provider? a. Blood pressure 90/50 mm Hg b. Respiratory rate 45/min c. Weight 14.5 kg (32 lb) d. Heart rate 110/min

b. Respiratory rate 45/min The nurse should identify that a respiratory rate of 45/min is above the expected reference range of 20 to 25/min for a 3-year-old toddler and can indicate respiratory dysfunction and acute respiratory distress. Therefore, the nurse should report this finding to the provider.

A nurse is providing discharge teaching to the guardians of a toddler who had lower leg cast applied 24 hr ago. The nurse should instruct the guardians to report which of the following finding to the provider? a. Capillary refill time less than 2 seconds b. Restricted ability to move the toes c. Swelling of the casted foot when the leg is dependent d. Pedal pulse +3 bilateral

b. Restricted ability to move the toes. The nurse should inform the guardians that a restricted ability of the toddler to move their toes is an indication of neurovascular compromise and requires immediate notification of the provider. Permanent muscle and tissue damage can occur in just a few hours. A capillary refill time that is greater than 2 seconds indicates circulatory compromise and should be reported to the provider immediately. Swelling of the casted foot when the leg is dependent is an expected finding. A pulse that is not easily obliterated with pressure is graded as a +3 and is an expected finding that indicates adequate circulation of the extremity. An absent pulse indicates circulatory compromise and should be reported to the provider immediately.

A nurse is caring for an adolescent who received a kidney transplant. Which of the following findings should the nurse identify as an indication the adolescent is rejecting the kidney? a. Negative leukocyte esterase b. Serum creatinine 3.0 mg/dL c. Negative urine protein d. Urine output 40 mL/hr

b. Serum creatinine 3.0 mg/dL Creatinine is a byproduct of protein metabolism and is excreted from the body through the kidneys. An elevated serum creatinine level, therefore, can be an indication that the kidneys are not functioning. The nurse should identify that the adolescent's serum creatinine level is higher than the expected reference range of 0.4 to 1.0 mg/dL for an adolescent and can indicate rejection of the kidney.

A nurse is reviewing the laboratory report of an infant who is receiving treatment for severe dehydration. The nurse should identify that which of the following laboratory values indicates effectiveness of the current treatment? a. Potassium 2.9 mEq/L b. Sodium 140 mEq/L c. Urine specific gravity 1.035 d. BUN 25 mg/dL

b. Sodium 140 mEq/L K = 4.1 - 5.3 mEq/L Na = 134 - 150 mEq/L USG = 1.005 - 1.030 BUN = 5 - 18 mg/dL

A nurse is caring for a 10-year-old child following a head injury. Which of the following findings should the nurse identify as an indication that the child is developing diabetes insipidus? a. Urine specific gravity 1.045 b. Sodium 155 mEq/L c. Blood glucose 45 mg/dL d. Urine output 35 mL/hr

b. Sodium 155 mEq/L A child who has a head injury can develop diabetes insipidus as a result of pituitary hypofunction leading to a deficiency of antidiuretic hormone. Underexcretion of antidiuretic hormone leads to polyuria and polydipsia, and possibly dehydration. With the excessive loss of free water, sodium levels rise above the expected reference range of 136 to 145 mEq/L.

The nurse is providing discharge teaching to the parent of a child who is 1 week postoperative following a cleft palate repair. For which of the following members of the inter professional team should the nurse initiate a referral? a. Occupational therapist b. Speech therapist c. Respiratory therapist d. Physical therapist

b. Speech therapist The nurse should initiate a referral for a speech therapist for a child who is postoperative following a cleft palate repair. A child who has a cleft palate will require speech therapy immediately following the repair to support speech development and future articulation.

A nurse is providing discharge teaching to the parent of an 18-month-old toddler who has dehydration due to acute diarrhea. Which of the following statements by the parent indicates an understanding of the teaching? a. "I will offer my child small amounts of fruit juice frequently." b. "I will avoid giving my child solid foods until the diarrhea has stopped." c. "I will monitor my child's number of wet diapers." d. "I will give my child polyethylene glycol daily for 7 days."

c. "I will monitor my child's number of wet diapers." The nurse should teach the parent to closely monitor the child's number of wet diapers. Monitoring the number of wet diapers per day is an effective way for the parent to monitor adequate output & hydration status. Children recovering from dehydration should not be encouraged to drink frequent, small amounts of fruit juice because it is high in carbohydrates, low in electrolytes, & has a high osmolality value. The nurse should teach the parent to encourage solid foods as soon as the toddler is rehydrated to provide adequate nutrient intake. Polyethylene glycol is an osmotic agent that will pull fluid into the bowel, increasing the frequency of stools, which will increase the level of dehydration.

A nurse is providing discharge teaching to the guardian of a school-age child who has undergone a tonsillectomy. Which of the following statements by the guardian indicates an understanding the teaching? a. "My child can resume usual activities since this was just an outpatient surgery." b. "My child will be able to drink the chocolate milkshake I promised to get for them tonight." c. "I will notify the doctor if I notice that my child is swallowing frequently." d. "I will have my child gargle with warm salt water to relieve their sore throat."

c. "I will notify the doctor if I notice that my child is swallowing frequently." The nurse should instruct the parent that frequent swallowing is an indication of bleeding and, if it is observed, to notify the provider immediately. Activity should be limited following a tonsillectomy to decrease the risk of hemorrhage. Milk products should be avoided because they coat the child's throat, which can initiate a cough response and increase the risk of bleeding. Brown and red foods should be avoided during the immediate postoperative period so that food and fresh or old blood are distinguishable in the child's emesis. Gargles are likely to cause irritation and discomfort and can increase the risk of bleeding following a tonsillectomy. The child should receive adequate pain medication following the procedure and can wear an ice collar if tolerated.

A nurse is providing discharge teaching to the parent of a school-age child who has moderate persistent asthma. Which of the following instructions should the nurse include? a. "You should give your child their salmeterol inhaler every 4 hours when they are having an acute episode of wheezing." b. "You should monitor your child's weight weekly while they are receiving inhaled corticosteroid therapy." c. "Pulmonary function tests will be performed every 12-24 months to evaluate how your child is responding to therapy." d. "When using the peak expiratory flow meter, record your child's average of three readings."

c. "Pulmonary function tests will be performed every 12-24 months to evaluate how your child is responding to therapy." The nurse should inform the parent that their child will need PFTs every 12-24 months to evaluate the presence of lung disease and how the child is responding to the current treatment regimen. As children grow, sometimes their manifestations can improve or decline, & treatment needs to change accordingly.

A nurse is teaching a school-age child and their parent about postoperative care following cardiac catheterization. Which of the following instructions should the nurse include? a. "Stay home from school for 1 week following the procedure." b. "Follow a diet that is low in fiber for 1 week." c. "Wait 3 days before taking a tub bath." d. "Apply a pressure dressing to the site for 3 days."

c. "Wait 3 days before taking a tub bath." The child should keep the site clean and dry for at least 3 days to reduce the risk of infection. Tub baths should be avoided for 3 days to avoid immersion of the incision in water. The child can attend school the next day but they should avoid strenuous activities to prevent bleeding at the insertion site. The child can resume their regular diet after the procedure. The parent can remove the pressure dressing the day after the procedure and should apply a new adhesive bandage strip daily to the site for at least the next 2 days.

A nurse in a providers office is caring for a school-age child who has varicella. The parents asks the nurse when their child will no longer be contagious. Which of the following responses should the nurse make? a. "When your child no longer has an increased temperature." b. "Three days after you first noticed the rash appear on your child." c. "When your child's lesions are crusted, usually 6 days after they appear." d. "Two to three weeks, when your child's lesions completely disappear."

c. "When your child's lesions are crusted, usually 6 days after they appear." The nurse should inform the parent that the child is contagious 1 day prior to lesion eruption and until the vesicles have crusted over, which usually takes about 6 days.

A nurse is caring for a preschooler who is scheduled for hydrotherapy treatment for wound debridement following a burn injury. Which of the following actions should the nurse take prior to the procedure? a. Apply topical antimicrobial ointment to the child's wound. b. Place a mesh gauze dressing over the child's wound. c. Administer an analgesic to the child. d. Initiate prophylactic antibiotic therapy for the child.

c. Administer an analgesic to the child. Hydrotherapy for debridement of a wound is an extremely painful procedure which requires analgesia and/or sedation. When pain is controlled, it leads to reduced physiological demands on the body caused by stress and decreases the likelihood of children developing depression and post-traumatic stress disorder. A nurse should apply topical antimicrobial ointment to the child's wound following hydrotherapy to prevent infection. A nurse should apply mesh gauze to the child's wound following hydrotherapy to prevent infection. Prophylactic antibiotic therapy is not recommended for children who have burns.

A nurse is preparing to administer an immunization to a 4-year-old child. Which of the following actions should the nurse plan to take? a. Place the child in a prone position for the immunization. b. Request that the child's caregiver leave the room during the immunization. c. Administer the immunization using a 24-gauge needle. d. Inject the immunization slowly after aspirating for 3 seconds.

c. Administer the immunization using a 24-gauge needle. The nurse should administer an immunization for a 4-year-old child using a 22- to 25- gauge needle to minimize the amount of pain the child experiences. The nurse should place the child in an upright sitting position for the immunization & allow the caregiver to stay near the child during the immunization to provide a sense of security and reduce the child's anxiety level. The nurse should inject the immunization rapidly and avoid aspiration. These actions decrease the risk of needle displacement and lower the child's fear and anxiety level by decreasing the amount of time it takes to administer the immunization.

A nurse is caring for a 1-month-old infant who is breastfeeding and requires a heel stick. Which of the following actions should the nurse take to minimize the infants pain? a. Use a manual lancet to obtain the heel blood sample. b. Apply an ice pack to the infant's heel prior to obtaining the sample. c. Allow the mother to breastfeed while the sample is being obtained. d. Apply a topical lidocaine cream prior to obtaining the sample.

c. Allow the mother to breastfeed while the sample is being obtained. The nurse should allow the mother to breastfeed the infant prior to or during the procedure. EBP indicates breastfeeding or non-nutritive sucking with a pacifier can provide nonpharmacological pain management in infants. The use of a manual lancet should be avoided because it can cause more discomfort. The nurse should apply a heating pad to the infant's heel prior to obtaining the sample. The use of topical lidocaine is not an effective pain management technique for a heel stick.

A nurse is caring for a school-age child who in in Buck's traction following a leg fracture 24 hr ago. Which of the following actions should the nurse take? a. Change the child's position every 2 hr. b. Clean the peripheral pin sites with chlorhexidine solution every 4 days. c. Assess peripheral pulses once every 4 hr. d. Ensure that the head of the bed is elevated to a 90° angle.

c. Assess peripheral pulses once every 4 hr. Buck's traction is a type of skin traction that can be used to immobilize extremities prior to surgery. The nurse should provide frequent neurovascular checks at least every 4 hr after the first 24 hr of placement in Buck's traction. The nurse should monitor & report signs of NV impairment in the extremities such as cyanosis, edema, pain, absent pulses, & tingling. The nurse should maintain the child in a supine position. Elevating the HOB should be implemented for a child who is in cervical traction. A child who requires skeletal traction will require pin site care.

A school nurse is caring for a child following tonic-clonic seizure. Which of the following actions should the nurse take first? a. Check the child for a head injury. b. Observe for oral bleeding. c. Check the child's respiratory rate. d. Observe for extremity weakness.

c. Check the child's respiratory rate. When using the airway, breathing, and circulation approach to client care, the nurse should determine the priority action is to assess the child's respiratory rate. If the child is not breathing, the nurse should administer rescue breaths.

A nurse in the emergency department is caring for a toddler who has a partial thickness burns on their right arm. Which of the following actions should the nurse take? a. Insert a nasogastric tube. b. Initiate prophylactic antibiotic therapy. c. Cleanse the affected area with mild soap and water. d. Apply a topical corticosteroid to the affected area.

c. Cleanse the affected area with mild soap and water. The nurse should wash the affected area with mild soap and water to remove any loose tissue that could cause infection. The nurse should be aware that inserting a NG tube to empty the contents of the stomach & maintain decompression is an intervention for major burn management. Antibiotics are not routinely administered for the prevention of infection at the burn site because the decreased circulation in the burned area decreases the distribution of the medication to the deeper tissues. The nurse should apply an antimicrobial ointment to the affected area to prevent infection.

A nurse is assessing a 4-year-old child at a well-child visit. Which of the following developmental milestones should the nurse expect to observe? a. Identifies right from left hand b. Uses a utensil to spread butter c. Cuts an outlined shape using scissors d. Draws a stick figure with seven body parts

c. Cuts an outlined shape using scissors. The nurse should recognize that an expected developmental milestone of a 4-year-old child is using scissors to cut out a shape. Identifying the right from left hand & using a utensil to spread butter is an expected developmental milestone of a 6-year-old child. Drawing a stick figure with seven body parts is an expected developmental milestone of a 5-year-old child.

A nurse assessing a school-age child who has an infratentorial brain tumor. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure? a. Hypotension b. Reports insomnia c. Difficulty concentrating d. Tachycardia

c. Difficulty concentrating The nurse should identify that irritability, inability to follow commands, & difficulty concentrating are manifestations of ICP due to decreased blood flow within the brain & pressure on the brainstem. The nurse should identify that hypertension & bradycardia is a late manifestation of ICP. Somnolence & lethargy are manifestations of ICP.

A charge nurse is preparing to make a room assignment for a newly admitted school-age child. Which of the following considerations is the nurses priority? a. Length of stay b. Treatment schedule c. Disease process d. Self-care ability

c. Disease process The transmission of infectious diseases is the greatest risk to this child & other children on the unit. Therefore, the child's disease process is the nurse's priority consideration

A nurse in an urgent care clinic is assessing an adolescent who has an upper respiratory tract infection. Which of the following findings should the nurse identify as a manifestation of pertussis? a. Inflamed throat with exudate b. Purulent eye drainage c. Dry, hacking cough d. Koplik spots on buccal mucosa

c. Dry, hacking cough The nurse should identify that a dry, hacking cough is a manifestation of pertussis. This disease usually begins with indications of an upper respiratory tract infection, which includes a dry, hacking cough that is sometimes more severe at night. The nurse should identify that an inflamed throat with exudate is a manifestation of acute streptococcal pharyngitis, purulent eye drainage is a manifestation of bacterial conjunctivitis, & Koplik spots on buccal mucosa are a manifestation of rubeola, or measles.

A nurse is reviewing the lumbar puncture results of a school-age child suspected of having bacterial meningitis. Which of the following results should the nurse identify as a finding associated with bacterial meningitis? a. Decreased cerebrospinal fluid pressure b. Decreased WBC count c. Increased protein concentration d. Increased glucose level

c. Increased protein concentration The nurse should identify that an increased protein concentration in the spinal fluid is a finding that can indicate bacterial meningitis. Increased CSF pressure and WBC count is a finding associated with bacterial meningitis. A decreased glucose level in the spinal fluid is a finding associated with bacterial meningitis.

A nurse is assessing an 8-year-old child who has early indications of shock. After establishing an airway and stabilizing the child's respirations, which of the following actions should the nurse take next? a. Insert an indwelling urinary catheter. b. Measure weight and height. c. Initiate IV access. d. Maintain ECG monitoring.

c. Initiate IV access. After establishing an airway and stabilizing the child's respirations, the next action the nurse should take when using the airway, breathing, and circulation approach to client care is to establish IV access to maintain the child's circulatory volume.

A nurse is caring for a 15 year-old client following a head injury. Which of the following findings should the nurse identify as an indication that the child is developing syndrome of inappropriate antidiuretic hormone secretion (SIADH)? a. Sodium 148 mEq/L b. Urine specific gravity 1.020 c. Mental confusion d. Weak peripheral pulses

c. Mental confusion A child who has a head injury can develop SIADH as a result of altered pituitary function, leading to an oversecretion of ADH. Oversecretion of ADH leads to a decrease in urine output, hyponatremia, & hypoosmolality due to overhydration. As the hyponatremia becomes more severe, mental confusion & other neurologic manifestations such as seizures can occur.

A nurse is preparing to collect a sample from a toddler for a sickle-turbidity test. Which of the following actions should the nurse plan to take? a. Obtain a sputum specimen. b. Perform an Allen test. c. Perform a finger stick. d. Obtain a stool specimen.

c. Perform a finger stick. The nurse should perform a finger stick on a toddler as a component of the sickle-turbidity test. If the test is positive, hemoglobin electrophoresis is required to distinguish between children who have the genetic trait and children who have the disease. Sputum specimens are collected to identify the infectious organism in a child who has an acute respiratory tract infection. An Allen test determines adequate circulation by observing capillary refill before an arterial puncture. Stool specimens are collected to identify organisms or parasites that cause diarrhea or to check for the presence of occult blood.

A nurse is caring for a newly admitted school-age child who has hypopituitarism. Which of the following medications should the nurse expect the provider to prescribe? a. Desmopressin b. Luteinizing hormone-releasing hormone c. Recombinant growth hormone d. Levothyroxine

c. Recombinant growth hormone Recombinant growth hormone injections are used to treat hypopituitarism, which inhibits cell growth and results in growth failure. The nurse should expect the provider to prescribe this treatment. Desmopressin is used to treat hyposecretion of ADH. LHR hormone is used in the treatment of precocious puberty to slow prepubertal growth in children & in the treatment of advanced prostate cancer in adult clients. Levothyroxine is used to treat various hypothyroid conditions.

A nurse is caring for a school-age child who is receiving chemotherapy and is severely immunocompromised. Which of the following actions should the nurse take? a. Use surgical asepsis when providing routine care for the child. b. Administer the measles, mumps, and rubella (MMR) vaccine to the child. c. Screen the child's visitors for indications of infection. d. Infuse packed RBCs.

c. Screen the child's visitors for indications of infection. A child who is severely immunocompromised is unable to adequately respond to infectious organisms, resulting in the potential for overwhelming infection. Therefore, the nurse should screen the child's visitors for indications of infection. It is not necessary for the nurse to use surgical asepsis when providing direct care. Strict hand hygiene and medical asepsis are recommended to prevent the spread of infection. The MMR vaccine is contraindicated for a child who is severely immunocompromised because it is a live virus vaccine and the child might not be able to build adequate antibodies to prevent infection with the organism. They will have a decreased neutrophil count. The nurse should plan to infuse PRBCs for the child who is anemic.

A nurse in an emergency department is assessing a 3-month-old infant who has rotavirus and is experiencing acute vomiting and diarrhea. Which of the following manifestations should the nurse identify as an indication that the infant has moderate to severe dehydration? a. Heart rate 124/min b. Increased tear production c. Sunken anterior fontanel d. Capillary refill 2 seconds

c. Sunken anterior fontanel The nurse should recognize that a sunken anterior fontanel is an indication of moderate to severe dehydration due to the acute loss of fluid. An infant who has moderate to severe dehydration is more likely to have absence of tears rather than increased tear production. HR & capillary refill are within expected range.

A nurse is auscultating the lungs of an adolescent who has asthma. The nurse should identify the sound as which of the following? a. Biot respiration b. Cheyne-Stokes respiration c. Tachypnea d. Bradypnea

c. Tachypnea The nurse should identify the sound heard during auscultation as tachypnea, which is a rapid, regular breathing pattern. This breathing pattern often occurs with anxiety, fever, metabolic acidosis, or severe anemia. Biot respirations as periods of apnea alternating with breaths of increased but consistent depth. Cheyne-Stokes respirations as periods of apnea alternating with periods of hyperventilation. Bradypnea as a slow, regular breathing pattern.

A nurse is assessing the vital signs of a 10-year-old child following a burn injury. The nurse should identify that which of the following findings in an indication of early septic shock? a. Blood pressure 130/90 mm Hg b. Heart rate 60/min c. Temperature 39.1° C (102.4° F) d. Urinary output 100 mL/hr

c. Temperature 39.1° C (102.4° F) The nurse should identify that a temperature of 39.1° C (102.4° F) is above the expected reference range of 37° to 37.5° C (98.6° to 99.5° F) for a 10-year-old child. The nurse should expect a child who has early septic shock to have a fever and chills.

A nurse is reviewing the dietary choices of an adolescent who has iron deficiency anemia. The nurse should identify that which of the following menu items has the highest amount of nonheme iron? a. ½ cup whole milk b. 1 cup orange juice c. ½ cup raisins d. 1 cup raw carrots

c. ½ cup raisins The nurse should encourage the adolescent to eat raisins because they contain the highest amount of nonheme iron. Whole milk does not contain the highest amount of nonheme iron. However, it does contain high amounts of calcium. Orange juice does not contain the highest amount of nonheme iron. However, it does contain ascorbic acid, which increases the amount of nonheme iron absorbed by the body. Raw carrots do not contain the highest amount of nonheme iron.

A nurse is providing discharge teaching to the parents of a 6-month-old infant who is postoperative following hypospadias repair with a stent placement. Which of the following instructions should the nurse include in the teaching? a. "You may bathe your infant in an infant bathtub when you go home." b. "Apply hydrocortisone cream to your infant's penis daily." c. "You should clamp your infant's stent twice daily." d. "Allow the stent to drain directly into your infant's diaper."

d. "Allow the stent to drain into your infants diaper." The nurse should instruct the parents to ensure that the stent drains directly into the infant's diaper to prevent kinking or twisting that can interfere with urine flow. Avoid blocking the stent to prevent urinary stasis and potential injury to the infant. Submerging the stent in water can cause infection at the operative site. The parents should avoid placing the infant in an infant bathtub until after the provider removes the stent. Following surgical repair of a hypospadias, the infant is at increased risk for infection at the operative site. The nurse should instruct the parents to administer a prophylactic antibiotic as prescribed to help prevent infection.

A nurse is providing discharge teaching to the parents of a 3-month old infant following a cheiloplasty. Which of the following instructions should the nurse include? a. "Clean your baby's sutures daily with a mixture of chlorhexidine and water." b. "Expect your baby to swallow more than usual over the next few days." c. "Inspect your baby's tongue for white patches using a tongue depressor every 8 hours." d. "Apply a thin layer of antibiotic ointment on your baby's suture line daily for the next 3 days."

d. "Apply a thin layer of antibiotic ointment on the your baby's suture line daily for the next 3 days." The nurse should instruct the parents to apply a thin layer of antibiotic ointment on the infant's suture line daily for 3 days & then continue to apply petroleum jelly to the area for several weeks to promote healing. The nurse should instruct the parents to clean the infant's sutures with sterile water or diluted hydrogen peroxide. The nurse should instruct the parents to notify the provider of excessive swallowing because this can indicate bleeding & the infant's swallowing of the blood. The nurse should instruct the parents to avoid placing objects, such as tongue depressors, in the infant's mouth to prevent injury to the suture line.

A nurse is teaching the parent of an infant about ways to prevent sudden infant death syndrome (SIDS). Which of the following instructions should the nurse include? a. "Place the infant in a prone position to sleep." b. "Allow the infant to sleep on a large pillow." c. "Use a soft mattress in the infant's crib." d. "Give the infant a pacifier at bedtime."

d. "Give the infant a pacifier at bedtime." The nurse should inform the parent that protective factors against SIDS include breastfeeding and the use of a pacifier when the infant is sleeping. Prone and side-lying positions are risk factors for SIDS. The nurse should instruct the parent to use a firm mattress and avoid the use of waterbeds, beanbags, or soft mattresses when placing the infant in bed. The use of a soft mattress in the infant's crib is a risk factor for SIDS and can lead to asphyxiation.

A nurse is teaching the parent of a preschooler about ways to prevent acute asthma attacks. Which of the following statements by the parent indicates an understanding of the teaching? a. "I will use a humidifier in my child's room at night." b. "I will give my child a cough suppressant every 6 hours if he has a cough." c. "I should avoid using a wet mop on my floors when I am cleaning." d. "I should keep my child indoors when I mow the yard."

d. "I should keep my child indoors when I mow the yard." The nurse should instruct the parent to keep the preschooler indoors during lawn maintenance or when the pollen count is increased. Guarding against exposure to known allergens found outdoors, such as grass, tree, & weed pollen, will decrease the frequency of the preschooler's asthma attacks.

A nurse is teaching the parent of an infant who has a Pavlik harness for the treatment of developmental dysplasia of the hip. The nurse should identify that which of the following statements by the parent indicates an understanding of the teaching? a. "I should remove the harness at night to allow my infant to stretch her legs." b. "I will need to adjust the straps on the harness once each week." c. "I should apply baby powder to my infant's skin twice daily." d. "I will place my infant's diapers under the harness straps."

d. "I will place my infant's diapers under the harness straps." To prevent soiling of the harness, the parent should apply the infant's diaper under the straps. The harness is to be worn continuously until the hip is stable, which usually occurs within 6-12 weeks. Removing the harness frequently or for long periods of time will reduce the effectiveness of the treatment. The Pavlik harness is designed to maintain the infant's hips in a position of flexion & abduction. The nurse should instruct the parent not to adjust the harness in any way to avoid complications. The use of powders & lotions should be avoided during treatment with a Pavlik harness because these products, in combination with the harness, can cause skin irritation and breakdown.

A school nurse is providing an in-service for faculty about improving education for students who have ADHD. Which of the following statements by a faculty member indicates an understanding of the teaching? a. "I will plan to increase the amount of homework I assign to students who have ADHD." b. "I will give students who have ADHD the same amount of time as other students to complete tests." c. "I will allow students who have ADHD one rest break throughout the day." d. "I will teach challenging academic subjects to students who have ADHD in the morning."

d. "I will teach challenging academic subjects to students who have ADHD in the morning." Faculty should plan to teach challenging academic subjects in the morning when students who have ADHD are most able to focus and their medication is most likely to be effective. Faculty should decrease the amount of school work and homework given to a child who has ADHD to maintain their attention & should be given additional time to take tests due to decreased attention. Faculty should allow frequent breaks throughout the day for students who have ADHD to modify their learning environment.

A hospice nurse is caring for a preschooler who has a terminal illness. The father tells the nurse that he cannot cope anymore and has decided to move out of the house. Which of the following statements should the nurse make? a. "It is important that you provide emotional support for your family at this time." b. "You have to do what you feel is best. Everything will turn out fine." c. "I know how you feel. This is an extremely stressful time for your family." d. "Let's talk about some of the ways you have handled previous stressors in your life."

d. "Let's talk about some of the ways you have handled previous stressors in your life." This statement offers a general lead to allow the parent to express their feelings and previous actions when faced with stressful situations. It also helps the parent to focus on ways that they can cope with the current situation.

A school nurse is assessing an adolescent who has scoliosis. Which of the following findings should the nurse expect? a. Increase in anterior convexity of the lumbar spine b. Increased curvature of the thoracic spine c. Lateral flexion of the neck d. A unilateral rib hump

d. A unilateral rib hump When assessing an adolescent for scoliosis, the school nurse should expect to see a unilateral rib hump with hip flexion. This results from a lateral S- or C-shaped curvature to the thoracic spine resulting in asymmetry of the ribs, shoulders, hips, or pelvis. Scoliosis can be the result of a neuromuscular or connective tissue disorder, or it can be congenital in nature. An increased anterior convexity of the lumbar spine is a manifestation of lordosis, an expected finding in toddlers. Lordosis can indicate a complication of a disease process, such as flexion contractures, congenital dislocation of the hip, or obesity, when seen in older children. An increased curvature of the thoracic spine is a manifestation of kyphosis. Lateral flexion of the neck is an indication of torticollis as a result of contracture of the sternocleidomastoid muscle. Torticollis can be congenital, the result of intrauterine fetal posturing or abnormality of the cervical spine, or it can be acquired, due to factors such as a traumatic lesion to the sternocleidomastoid muscle.

A nurse in an emergency department is caring for a school-age child who is experiencing an anaphylactic reaction. Which of the following is the priority action by the nurse? a. Elevate the head of the child's bed. b. Insert a large bore IV catheter for the child. c. Determine the allergen that caused the child's reaction. d. Administer epinephrine IM to the child.

d. Administer epinephrine IM to the child. When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority action is administering epinephrine IM to the child. During an anaphylactic reaction, histamine release causes bronchoconstriction and vasodilation. This is an emergency because ultimately this causes decreased blood return to the heart.

A nurse is performing hearing screenings for children at a community health fair. Which of the following children should the nurse refer to a provider for a more extensive hearing evaluation? a. An 18-month-old toddler who has unintelligible speech b. A 3-month-old infant who has an exaggerated startle response c. A 4-year-old preschooler who prefers playing with others rather than alone d. An 8-month-old infant who is not yet making babbling sounds

d. An 8-month-old who is not yet making babbling sounds. The nurse should refer an infant who is not making babbling sounds by the age of 7 months to a provider for a more extensive evaluation of hearing.

A nurse is planning care for a newly admitted school-aged child who has generalized seizure disorder. Which of the following interventions should the nurse plan to include? a. Ensure that a padded tongue blade is at the child's bedside. b. Allow the child to play video games on a tablet computer. c. Allow the child to take a tub bath independently. d. Ensure the oxygen source is functioning in the child's room.

d. Ensure the oxygen source is functioning in the child's room The nurse should recognize that maintaining the child's airway is important during a seizure. The nurse should ensure that the oxygen source is functioning because the child might require supplemental oxygen following a seizure. Nothing should be placed in the child's mouth during or after a seizure. Therefore, placing a padded tongue blade at the child's bedside is not an action the nurse should take. Bright or flashing lights from video games can trigger seizure activity. The nurse should decrease environmental stimuli & offer other play activities, such as reading a book or playing with a stuffed animal. The nurse should allow the child to take a tub bath with supervision, but not independently. There should be someone available to assist the child if they experience a seizure.

A nurse is discussion organ donation with the parents of a school-age child who has sustained brain death due to a bicycle crash. Which of the following actions should the nurse take first? a. Inform the parents that written consent is required prior to organ donation. b. Provide written information to the parents about organ donation. c. Ask the provider to explain misconceptions of organ donation to the parents. d. Explore the parents' feelings and wishes regarding organ donation.

d. Explore the parents feelings and wishes regarding organ donation. The first action the nurse should take when using the nursing process is assessment. The nurse should first explore the parents' feelings & wishes regarding organ donation to assist in determining if organ donation is the right choice for the family.

A nurse is providing anticipatory guidance to the parent of a toddler. Which of the following expected behavior characteristics of toddlers should the nurse include? a. Controls impulsive feelings b. Understands right from wrong c. Easily separates from parents for long periods of time d. Expresses likes and dislikes

d. Expressed likes and dislikes The nurse should include that expressing likes & dislikes is an expected behavior of toddlers. This is the time in life when a toddler is developing autonomy & self-concept. They will try to assert themselves & frequently refuse to comply. The parent should allow the child to have some control, but also set limits for them so they learn from their behavior & learn to control their actions. Controlling impulsive feelings is an expected behavior of school-age children. A toddler is more likely to have difficulty controlling strong & impulsive feelings as they try to assert their independence & gain control of situations. Understanding right from wrong & modifying their behavior in response to others' expectations is an expected behavior of preschoolers. Toddlers tend to have a great deal of curiosity & ask many questions but are not able to fully understand what behaviors are right or wrong. A toddler might be able to separate from their parents for a short period of time, but the toddler is more likely to experience acute separation anxiety when separated from their parents for an extended period of time. The toddler might offer resistance if they are left with a new babysitter or at a new day care center.

A nurse is creating a plan of care for a newly admitted adolescent who has bacterial meningitis. How long should the nurse plan to maintain the adolescent in droplet precautions? a. Until the adolescent is afebrile b. For 7 days following admission to the facility c. Until the adolescent has a negative blood culture d. For 24 hr following initiation of antimicrobial therapy

d. For 24 hr following initiation of antimicrobial therapy The nurse should plan to maintain the adolescent on droplet precautions for at least 24 hr following initiation of antimicrobial therapy. This practice will ensure that the adolescent is no longer contagious, which protects family members and the personnel caring for the client. Prophylactic antibiotics might be prescribed to individuals who were in close contact with the adolescent.

A nurse is creating a plan of care for an infant who has an epidural hematoma from a head injury. Which of the following interventions should the nurse include in the plan? a. Position the infant side-lying with their head at a 0° to 5° angle. b. Perform a neurological assessment every 4 hr. c. Suction the infant's nares to remove secretions. d. Implement seizure precautions for the infant.

d. Implement seizure precautions for the infant. An infant who has an epidural hematoma is at great risk for seizure activity. Therefore, the nurse should implement seizure precautions for the child. The nurse should position the infant with their head slightly elevated in a midline position to reduce the risk of increased intracranial pressure. The nurse should perform a neurological assessment as frequently as every 15 min to detect changes in the child's condition and monitor for intracranial pressure. The nurse should avoid suctioning the infant's nares due to the risk of exposure of the suction catheter to the brain through the fracture; however, oral suctioning can be performed.

A nurse is planning care to address nutritional needs for a preschooler who has cystic fibrosis. Which of the following interventions should the nurse include in the plan? a. Administer pancreatic enzymes 2 hr after meals. b. Discontinue the use of pancreatic enzymes if steatorrhea develops. c. Limit fluid intake to 750 mL per day. d. Increase fat content in the child's diet to 40% of total calories.

d. Increase fat content in the childs diet to 40% of total calories. A child who has cystic fibrosis is unable to properly digest fats due to fibrosis of the pancreas & limited secretion of pancreatic enzymes. The nurse should increase the child's fat intake to 35-40% of total caloric intake. The nurse should plan to administer pancreatic enzymes within 30 min of meals & snacks to replace the enzymes lost with cystic fibrosis. A child who has cystic fibrosis & develops steatorrhea, or fatty stools, might need to have their dosage of pancreatic enzyme increased by their provider until the steatorrhea resolves. The nurse should encourage fluid intake, rather than restrict it, to prevent dehydration caused by the loss of sodium & chloride through perspiration.

A nurse is creating a plan of care for a child who has varicella. Which of the following interventions should the nurse include? a. Maintain the child's room temperature at 80° F. b. Prepare the child for a lumbar puncture. c. Administer aspirin to the child for a temperature greater than 38.3° C (101° F). d. Initiate airborne precautions for the child.

d. Initiate airborne precautions for the child. The nurse should initiate airborne precautions for a child who has varicella because it is spread through droplets in the air. The incubation period for varicella is 2-3 weeks, & the child is contagious even before lesions appear. The nurse should ensure that a child who has varicella remains cool. Cooler temperatures decrease pruritis. Maintaining the child's room at a warm temperature will increase the child's discomfort. The nurse should prepare a child who has bacterial meningitis for a lumbar puncture. Guardians should be instructed to avoid the administration of aspirin when the child has a viral varicella infection due to the possibility of causing the development of Reye syndrome, which can be fatal.

A nurse is admitting a school-age child who has Pertussis. Which of the following actions should the nurse take? a. Place the child in a room with positive-pressure airflow. b. Place the child in a room with negative-pressure airflow. c. Initiate contact precautions for the child. d. Initiate droplet precautions for the child.

d. Initiate droplet precautions for the child. The nurse should initiate droplet precautions for a child who has pertussis, also known as whooping cough. Pertussis is transmitted through contact with infected large-droplet nuclei that are suspended in the air when the child coughs, sneezes, or talks.

A nurse is planning care for a school-age child who is in the oliguric phase of acute kidney injury (AKI) and has a sodium level of 129 mEq/L. Which of the following interventions should the nurse include in the plan? a. Administer ibuprofen to the child for a temperature greater than 38º C (100.4º F). b. Assess the child's blood pressure every 8 hr. c. Weigh the child weekly at various times of the day. d. Initiate seizure precautions for the child.

d. Initiate seizure precautions for the child. A sodium level of 129 mEq/L indicates hyponatremia and places the child at increased risk for neurological deficits and seizure activity. The nurse should complete a neurologic assessment and implement seizure precautions to maintain the child's safety.

A nurse is caring for a toddler who is experiencing acute diarrhea and has moderate dehydration. Which of the following nutritional items should the nurse offer to the toddler? a. Apple juice b. Peanut butter c. Chicken broth d. Oral rehydration solution

d. Oral rehydration solution A toddler who has acute diarrhea should consume an oral rehydration solution to replace electrolytes and water by promoting the reabsorption of water and sodium. This promotes recovery from dehydration. Apple juice because is high in carbohydrates and osmolarity and low in electrolytes. Peanut butter because it is high in carbohydrates and fiber. The high sugar content can result in prolonging the diarrhea and worsening of the dehydration, because water is pulled into the bowel lumen in response to the increased osmolality caused by the sugar. The fiber content further stimulates the bowel, worsening the diarrhea. Chicken broth is high in sodium and is not nutrient-dense.

A nurse is providing teaching about social development to the parents of a preschooler. Which of the following play activities should the nurse recommend for the child? a. Playing pat-a-cake b. Using a push-pull toy c. Creating a scrapbook d. Playing dress-up

d. Playing dress-up The nurse should instruct the parents that at the preschool age, play should focus on social, mental, and physical development. Therefore, playing dress-up is a recommended play activity for this child. Playing pat-a-cake is a recommended play activity for an infant. Using a push-pull toy is a recommended play activity for a toddler. Creating a scrapbook is a recommended play activity for a school-age child.

A community health nurse is assessing an 18-month-old toddler in a community day care. Which of the following findings should the nurse identify as a potential indication of physical neglect? a. Resists having an axillary temperature taken b. Exhibits withdrawal behaviors when their parent leaves c. Has multiple bruises on their knees d. Poor personal hygiene

d. Poor personal hygiene A toddler who has poor personal hygiene can be a potential indication of physical neglect. Because toddlers are still dependent on their parents or guardians for help with hygiene needs, poor personal hygiene can indicate a lack of supervision.

A nurse is caring for a preschooler who has congestive heart failure. The nurse observes wide QRS complexes and peaked T waves on the cardiac monitor. Which of the following prescriptions should the nurse clarify with the provider? a. Furosemide b. Captopril c. Regular insulin d. Potassium chloride

d. Potassium Chloride The nurse should identify that a child who has congestive heart failure can develop electrolyte imbalances, such as hyperkalemia or hypokalemia. The nurse should identify that the child is exhibiting manifestations of hyperkalemia and contact the provider about the administration of potassium chloride, which can increase the severity of hyperkalemia.

A nurse is planning care for a toddler who has a serum lead level of 4 mcg/dL. Which of the following actions should the nurse plan to take? a. Instruct the parents to decrease the calcium in their toddler's diet. b. Prepare the toddler for chelation therapy. c. Refer the family to Child Protective Services. d. Schedule the toddler for a yearly rescreening.

d. Schedule the toddler for a yearly rescreening. The nurse should schedule the toddler for a lead level rescreening in 1 year and educate the family on ways to prevent exposure. A serum lead level of 4 mcg/dL does not require a report to Child Protective Services because it is not an indicator of child endangerment. Chelation therapy is required for a lead level of 45 mcg/dL or greater and, depending on the situation, can be initiated for lead levels over 10 mcg/dL. The nurse should instruct the toddler's parents to provide a diet rich in calcium because calcium, vitamin C, and iron decrease lead absorption.

A nurse in an emergency department is performing an admission assessment on a 2 week-old male newborn. Which of the following findings is the priority for the nurse to report to the provider? a. Excoriated scrotal area b. Multiple capillary hemangiomas c. Depressed posterior fontanel d. Substernal retractions

d. Substernal retractions When using the airway, breathing, and circulation approach to client care, the nurse should determine that the priority finding to report to the provider is substernal retractions. This finding indicates the newborn is experiencing increased respiratory effort, which could quickly progress to respiratory failure.

A nurse is assessing a toddler who has gastroenteritis and is exhibiting manifestations of dehydration. Which of the following findings is the nurses priority? a. Skin breakdown b. Hypotension c. Hyperpyrexia d. Tachypnea

d. Tachypnea When using the airway, breathing, and circulation approach to client care, the nurse's priority finding is the toddler's tachypnea. Tachypnea is a result of the kidneys being unable to excrete hydrogen ions and produce bicarbonate, which leads to metabolic acidosis.

The nurse is interviewing the parent of an 18-month-old toddler during a well-child visit. The nurse should identify that which of the following findings indicates a need to assess the toddler for hearing loss? a. The toddler has a vocabulary of 25 words. b. The toddler developed a mild rash following a recent varicella immunization. c. The toddler's Moro reflex is absent. d. The toddler received tobramycin during a hospitalization 2 weeks ago.

d. The toddler received tobramycin during a hospitalization 2 weeks ago. The nurse should identify tobramycin as an aminoglycoside, which is an ototoxic medication that can cause mild to moderate hearing loss, and should assess the toddler for a hearing impairment. A toddler should have a vocabulary of at least 10. Therefore, a vocabulary of 25 words does not indicate a need to assess the toddler for hearing loss. Approximately 1/25 people develop a mild rash following administration of the varicella vaccine. This reaction does not indicate a need to assess the toddler for hearing loss. Primitive reflexes, such as Moro, rooting, & tonic neck, disappear by 5 months of age.

A nurse is planning care for a school-age child who has tunneled central venous access device. Which of the following interventions should the nurse include in the plan? a. Use sterile scissors to remove the dressing from the site. b. Irrigate each lumen weekly with 10 mL of 0.9% sodium chloride solution when not in use. c. Access the site using a noncoring angled needle. d. Use a semipermeable transparent dressing to cover the site.

d. Use a semipermeable transparent dressing to cover the site The nurse should cover the site with a semipermeable transparent dressing to reduce the risk of infection. The nurse should avoid the use of scissors when performing dressing changes because this can result in accidental cutting of the catheter. The nurse should flush each lumen of the catheter with a heparin solution daily when not in use. The nurse should use a noncoring angled or straight needle when accessing an implanted port.

A nurse is proving dietary teaching to the parent of a school-age child who has celiac disease. The nurse should recommend that the parent offer which of the following foods to the child? a. Wheat crackers b. Rye bread c. Barley soup d. White rice

d. White rice The nurse should recommend that the parent offer white rice to the child because it is a gluten-free food. The nurse should instruct the parent that the child will remain on a lifelong gluten-free diet and the child should not consume oats, rye, barley, or wheat, and sometimes lactose deficiency can be secondary to this disease.