Ch 31, 35, & 37
The nurse is determining the amount of IV fluids to administer in a 24-hour period to a child who weighs 40 kg. How many milliliters should the nurse administer? A) 1,000 mL B) 1,500 mL C) 1,750 mL D) 1,900 mL
D) 1,900 mL
After teaching the mother about follow-up immunizations for her daughter, who received the varicella vaccine at age 14 months, the nurse determines that the teaching was successful when the mother states that a follow-up dose should be given at which time? A) When the child is 20 to 36 months of age B) When the child is 4 to 6 years of age C) When the child is 11 to 12 years of age D) When the child is 13 to 15 years of age
B
When preparing to administer the polio vaccine to an infant, the nurse would expect to administer the vaccine by which route? A) Intramuscular B) Subcutaneous C) Oral D) Intradermal
B
The nurse is preparing to administer insulin to a diabetic child. Which of the following would be the recommended route for this administration? A) Subcutaneous B) Intradermal C) Intramuscular D) Oral
A) Subcutaneous
During a physical assessment of a 5-month-old child, the nurse observes the first tooth has just erupted and uses the opportunity to advise the mother to schedule a dental examination for her baby. Which of the following is the correct time for the dentist visit? A) By the first birthday B) By the second birthday C) By entry into kindergarten D) By entry into first grade
A
The nurse working in a community clinic attempts to establish a free vaccination program to refer low-income families. What is the key strategy for success when implementing a health promotion activity? A) Partnership development B) Funding for projects C) Finding an audience D) Adequate staffing
A
The nurse is providing care for a 10-year-old girl who has required multiple venipunctures and a computed tomography (CT) scan in a single day. The girl has expressed no fear or need for comfort. How should the nurse respond? A) "Tell me about your day today." B) "Are you doing okay?" C) "Are you feeling okay?" D) "You have done really well today."
A) "Tell me about your day today."
The nurse is choosing a vein to insert a peripheral IV for a 2-year-old child. Which of the following sites would be appropriate? Select all answers that apply. A) Hand veins B) Feet veins C) Jugular vein D) Forearm veins E) Scalp veins F) Vena cava
A, B, D, E A) Hand veins B) Feet veins D) Forearm veins E) Scalp veins
9. The nurse is preparing to administer medication to a child with a gastrostomy tube in place. Which of the following is a recommended guideline for this procedure? Select all answers that apply. A) Verify proper tube placement prior to instilling medication. B) Mix liquid medications with a small amount of water and add directly into the tube. C) Mix powdered medications well with cold water first. D) Crush tablets and mix with warm water to prevent tube occlusion. E) Open up capsules and mix the contents with warm water. F) Flush the tube with water after administering medications.
A, D, E, F A) Verify proper tube placement prior to instilling medication. D) Crush tablets and mix with warm water to prevent tube occlusion. E) Open up capsules and mix the contents with warm water. F) Flush the tube with water after administering medications.
A woman gives birth to a healthy newborn. As part of the newborn's care, the nurse instills erythromycin ophthalmic ointment as a preventive measure for which sexually transmitted infection (STI)? A)Genital herpes B)Hepatitis B C)Syphilis D)Gonorrhea
Ans: D Feedback:To prevent gonococcal ophthalmia neonatorum, erythromycin or tetracycline ophthalmic ointment is instilled into the eyes of all newborns. This action is required by law in most states. The ointment is not used to prevent conditions related to genital herpes, hepatitis B, or syphilis.
The nurse is providing instructions to parents of a 2-year-old child with a fever. The child weighs 33 pounds. Based on the recommended dose for ibuprofen, how much would the nurse instruct the parents to give as the lowest amount per dose? ____________ mg
Ans: 75 mg Feedback:The child weighs 33 pounds, which is equivalent to 15 kg. The recommendations for ibuprofen are 5 to 10 mg/kg/dose. The lowest dose would be 5 × 15 kg or 75 mg. The largest recommended dose would be 150 mg (10 mg/kg × 15 kg).
After teaching a class on the role of white blood cells in infection, the instructor determines that the teaching was successful when the class identifies which type of white blood cells as important in combating bacterial infections? A)Neutrophils B)Eosinophils C)Basophils D)Lymphocytes
Ans: A Feedback:Elevations in certain portions of the white blood cell count reflect different processes occurring in the body. Neutrophils function to combat bacterial infection. Eosinophils function in allergic disorders and parasitic infections. Basophils combat parasitic infections and some allergic disorders. Lymphocytes function in viral infections.
The nurse is performing a physical examination of an 8-year-old girl who was bitten by her kitten. Which of the following assessments would lead the nurse to suspect cat-scratch disease? A)Swollen lymph nodes B)Strawberry tongue C)Infected tonsils D)Swollen neck
Ans: A Feedback:Lymph nodes, especially under the arms, can become painful and swollen due to cat-scratch disease. Strawberry tongue is typical of scarlet fever. Infected tonsils and an edematous neck are symptoms of diphtheria.
The nurse is preparing to obtain a blood specimen via capillary heel puncture. Which of the following would be most appropriate for the nurse to do? A)Apply a cool compress for several minutes before collection B)Elevate the extremity used after puncturing it C)Squeeze the area to facilitate specimen collection D)Wipe away the first drop of blood with dry gauze
Ans: D Feedback:When obtaining a blood specimen by capillary puncture, the nurse should wipe away the first drop of blood with a cotton ball or dry gauze pad and then collect the sample without squeezing the foot to prevent possible hemolysis. Prior to the puncture, the nurse can apply a commercial heel warmer or warm compress for several minutes to promote vasodilation. The extremity being used should be placed in the dependent position after puncturing the heel.
The nurse is discussing vaccination for Haemophilus influenzae type B (Hib) with the mother of a 6-month-old child. Which of the following comments provides the most compelling reason to get the vaccination? A) "These bacteria live in every human." B) "Young children are especially susceptible to these bacteria." C) "You have a choice of two excellent vaccines." D) "Your child needs this final dose for protection."
B
The nurse is explaining the difference between active and passive immunity to the student nurse. Which of the following statements accurately describes a characteristic of the process of immunity? A) Active immunity is produced when the immunoglobulins of one person are transferred to another. B) Passive immunity can be obtained by injection of exogenous immunoglobulins. C) Active immunity can be transferred from mothers to infants via colostrum or the placenta. D) Passive immunity is acquired when a person's own immune system generates the immune response.
B
The nurse is caring for an 8-year-old girl who requires medication that is only available in an enteric tablet form. The nurse is teaching the mother how to help the girl swallow the medication. Which of the following statements indicates a need for further teaching? A) "I can encourage her to place it on the back of her tongue." B) "I can pinch her nose to make it easier to swallow." C) "We cannot crush this type of pill as it will affect the delivery of the medication." D) "We can place the tablet in a spoonful of applesauce."
B) "I can pinch her nose to make it easier to swallow."
The nurse is providing teaching on how to administer nasal drops. Which of the following responses by the parents indicates a need for further teaching? A) "We need to be careful not to stimulate a sneeze." B) "She needs to remain still for at least 10 minutes after administration." C) "Our daughter should lie on her back with her head hyperextended." D) "We must not let the dropper make contact with the nasal membranes."
B) "She needs to remain still for at least 10 minutes after administration."
The nurse is providing teaching for the mother of an infant who receives all of his nutrition through a tube. The nurse is reviewing interventions to promote growth and development. Which of the following responses from the mother indicates a need for further teaching? A) "I will give him a pacifier during feeding time." B) "We need to keep feeding time very quiet." C) "We need to make sure he doesn't lose the desire to eat by mouth." D) "Sucking produces saliva, which aids in digestion."
B) "We need to keep feeding time very quiet."
The nurse is preparing to administer a medication to a 5-year-old who weighs 35 pounds. The prescribed single dose is 1 to 2 mg/kg/day. Which of the following is the appropriate dose range for this child? A) 8 to 16 mg B) 16 to 32 mg C) 35 to 70 mg D) 70 to 140 mg
B) 16 to 32 mg
A nurse has just administered medication via an orogastric tube. What is the priority nursing action following administration? A) Check tube placement. B) Retape the tube. C) Flush the tube. D) Remove the tube.
C) Flush the tube.
The nurse is administering immunizations to children in a neighborhood clinic. Which of the following is the most frequent route of administration? A) Oral B) Intradermal C) Intramuscular D) Topical
C) Intramuscular
The nurse is explaining to the student nurse the therapeutic effects of total parenteral nutrition (TPN). Which of the following accurately describes the use of TPN? A) It is used short term to supply additional calories and nutrients as needed. B) It is delivered via the peripheral vein to allow rapid dilution of hypertonic solution. C) It is a highly concentrated solution of carbohydrates, electrolytes, vitamins, and minerals. D) It is usually used when the child's nutritional status is within acceptable parameters.
C) It is a highly concentrated solution of carbohydrates, electrolytes, vitamins, and minerals.
After administering eye drops to a child, the nurse applies gentle pressure to the inside corner of the eye at the nose for which reason? A) To promote dispersion over the cornea B) To enhance systemic absorption C) To ensure the medication stays in the eye D) To stabilize the eyelid
C) To ensure the medication stays in the eye
When describing the differences affecting the pharmacokinetics of drugs administered to children, which of the following would the nurse include? A) Oral drugs are absorbed more quickly in children than adults. B) Absorption of intramuscularly administered drugs is fairly constant. C) Topical drugs are absorbed more quickly in young children than adults. D) Absorption of drugs administered by subcutaneous injection is increased.
C) Topical drugs are absorbed more quickly in young children than adults.
The nurse is administering Tylenol PRN to a 9-year-old child on the pediatric ward of the hospital. Which of the following reflect nursing actions that follow the rules of the "eight rights" of pediatric medication administration? Select all answers that apply. A) The nurse identifies the child by checking the name on the child's chart. B) The nurse makes sure the medication is given within the hour of the ordered time. C) The nurse checks the documented time of the last dosage administered. D) The nurse calculates the dosage according to the child's weight. E) The nurse explains the therapeutic effects of the medication to the child and parents. F) The nurse administers the medication even though the child is adamant about not taking it.
C, D, E C) The nurse checks the documented time of the last dosage administered. D) The nurse calculates the dosage according to the child's weight. E) The nurse explains the therapeutic effects of the medication to the child and parents.
A 15-month-old girl is having her first health visit at a clinic. The mother has no immunization record but says the child was immunized 3 months ago at the local health department. Which of the following is the best action for the nurse to take? A) Ask the mother to bring the records to the next health maintenance visit. B) Start the catch-up schedule since there are no immunization records. C) Keep the child at the facility while the mother returns home for the records. D) Call the local health department and verify the child's immunization status.
D
A mother and her 4-week-old infant have arrived for a health maintenance visit. Which of the following activities will the nurse perform? A) Assess the child for an upper respiratory infection B) Take a health history for a minor injury C) Administer a varicella injection D) Plot the child's head circumference on a growth chart
D
The nurse is administering a hepatitis B vaccine to a child. What is the classification of this type of vaccine? A) Killed vaccines B) Toxoid vaccines C) Conjugate vaccines D) Recombinant vaccines
D
The nurse is administering a liquid medication to a 3-year-old using an oral syringe. Which action would be most appropriate? A) Direct the liquid toward the anterior side of the mouth. B) Keep the child's hand away from the oral syringe when squirting the medication. C) Give all of the drug in the syringe at one time with one squirt. D) Allow the child time to swallow the medication in between amounts.
D) Allow the child time to swallow the medication in between amounts.
A nurse is caring for a 14-year-old with a gastrostomy tube. The girl has skin breakdown and irritation at the insertion site. Which of the following would be the most appropriate method to clean and secure the gastrostomy tube? A) Make sure the tube cannot be moved in and out of the child's stomach. B) Use adhesive tape to tape the tube in place and prevent movement. C) Place a transparent dressing over the site whether there is drainage or not. D) If any drainage is present, use a presplit 2 × 2 and place it loosely around the site.
D) If any drainage is present, use a presplit 2 × 2 and place it loosely around the site.
The nurse is preparing to administer ear drops to a 6-year-old. To ensure that the medication is instilled properly, the nurse does which of the following? A) Pulls the pinna downward B) Pulls the pinna downward and back C) Pulls the pinna upward D) Pulls the pinna upward and back
D) Pulls the pinna upward and back
The nurse is helping a 14-year old boy who has asthma to administer medication via an inhaler. Which of the following describes a developmentally appropriate nursing intervention for this child? A) Involve the adolescent's parents in the administration of the medication. B) Allow the adolescent to handle a demo inhaler prior to administering the medication. C) Offer the adolescent a special treat if he uses his inhaler correctly. D) Treat the adolescent as an adult when explaining the use of the inhaler.
D) Treat the adolescent as an adult when explaining the use of the inhaler.
The nurse is teaching the student nurse the factors that affect the pharmacodynamics of the drugs they are administering. Which of the following is a factor affecting this property of drugs? A) Immature body systems B) Weight C) Body surface D) Body composition
A) Immature body systems
The nurse is caring for a 6-year-old child who has multisystem trauma due to a motor vehicle accident. The child is receiving total parenteral nutrition (TPN). Which of the following is a recommended nursing intervention for children on TPN? A) Initially, check blood glucose levels frequently, such as every 4 to 6 hours, to evaluate for hyperglycemia. B) Be vigilant in monitoring the infusion rate, change the rate as necessary, and report any changes to the physician or nurse practitioner. C) If for any reason the TPN infusion is interrupted or stops, begin an infusion of a 10% saline at the same infusion rate as the TPN. D) Administer TPN continuously over an 8-hour period, or after initiation it may be given on a cyclic basis, such as over a 12-hour period during the night.
A) Initially, check blood glucose levels frequently, such as every 4 to 6 hours, to evaluate for hyperglycemia.
The nurse is administering a crushed tablet to an 18-month-old infant. Which of the following is a recommended guideline for this intervention? A) Mix the crushed tablet with a small amount of applesauce. B) Place the crushed tablet in the infant's formula. C) Mix the crushed tablet with the infant's cereal. D) Crushed tablets should only be mixed with water.
A) Mix the crushed tablet with a small amount of applesauce.
The parents of a 5-year-old have just found out that their child has head lice. Which statement by the parents would support the nursing diagnosis of deficient knowledge? A)"I can't believe it. We're not unclean, poor people." B)"We'll have to get that special shampoo." C)"Everybody in the house will need to be checked." D)"That explains his complaints of itching on his neck."
Ans: A Feedback:Head lice is not an indication of poor hygiene or poverty. It occurs in all socioeconomic groups. Thus, the parents' statement about being unclean and poor reflects a lack of knowledge about the infection. A pediculicide is used to wash the hair to treat the infestation. Household contacts need to be examined and treated if affected. Extreme pruritus is the most common symptom, with nits or lice especially behind the ears or at the nape of the neck.
A mother brings her 8-year-old son for evaluation because of a rash on his lower leg. Which finding would support the suspicion that the child has Lyme disease? A)Playing in the woods about a week ago B)Rash is papular and vesicular C)High fever occurring about 4 days before the rash D)Complaints of extreme pruritus with visible nits
Ans: A Feedback:Lyme disease is caused by the bite of an infected tick, with a rash appearing 7 to 14 days after the tick bite. Ticks are commonly found in wooded areas. Therefore, reports of the child playing in the woods about 7 days ago would support the diagnosis of Lyme disease. A papular and vesicular rash is commonly associated with varicella (chickenpox). A high fever for 3 to 5 days before a rash suggests roseola. Extreme pruritus with visible nits would suggest pediculosis.
The nurse determines that it is necessary to implement airborne precautions for children with which of the following infections? A)Measles B)Streptococcus group A C)Rubella D)Scarlet fever
Ans: A Feedback:Airborne precautions are designed to reduce the risk of infectious agents transmitted by airborne droplet nuclei or dust particles such as for children with measles, varicella, or tuberculosis. Droplet precautions would be used for children with streptococcal group A infections, rubella, and scarlet fever.
A nurse suspects that an adolescent may have community-acquired methicillin-resistant Staphylococcus aureus (CAMRSA). Which of the following would the nurse expect to assess? Select all answers that apply. A)Participation in contact sport B)Recent cut on the lower leg C)History of a recent sort throat D)Raised fluctuant lesions E)Erythematous rash over the trunk and face
Ans: A, B, D Feedback:With CAMRSA, skin and tissue infections are common, often appearing as a bump or skin area that is red, swollen, painful, and warm to the touch. There also may be fluctuance and purulent drainage. Participation in contact sports, openings in the skin such as abrasions and cuts, contact with contaminated items and surfaces, poor hygiene, and crowded living conditions are risk factors for CAMRSA. Recent sore throat and an erythematous rash on the trunk, face, and possibly the extremities are associated with scarlet fever.
A nursing instructor is teaching a group of students about the action of antipyretic agents in children. The instructor determines that the teaching has been successful when the students identify which of the following as the primary action? A)Cause vasodilation to promote heat loss B)Decrease the temperature set point C)Block release of histamine D)Promote prostaglandin production
Ans: B Feedback:Antipyretics act to decrease the temperature set point in children with elevated temperatures by inhibiting the production of prostaglandins, which leads to heat loss through vasodilation and sweating. Antihistamines block the release of histamine
A group of nursing students are reviewing the six links in the chain of infection and the nursing implications for each. The students demonstrate understanding of the information when they identify which precaution as helping to break the chain of infection to the susceptible host? A)Keeping linens dry and clean B)Maintaining skin integrity C)Washing hands frequently D)Coughing into a handkerchief
Ans: B Feedback:Maintaining the integrity of the child's skin and mucous membranes is a precaution that will break the chain of infection at the susceptible host. Keeping linens dry and clean is a precaution to take at the reservoir link. Washing hands frequently breaks the chain at the mode of transmission. Coughing into a handkerchief is a precaution for the portal of exit.
A nurse is conducting a health history for a 1-month-old with an infectious disorder. Which segment of the health history would be most helpful for the nurse when determining if the infant developed the infection from the mother? A)Family history B)Past medical history C)Home treatments D)Present illness history
Ans: B Feedback:Past medical history will provide information about the mother's pregnancy and delivery, giving insight into the possibility of maternal transmission of the infection. Family history would provide information about lack of immunizations or recent infectious or communicable diseases. Home treatments and present illness history would provide no information about the possibility of maternal transmission of infection.
A 3-year-old boy has been on chemotherapy for cancer. He complains about a sore throat, is experiencing malaise, and has a temperature of 99.8°F orally. His mother calls the child's physician. What is the appropriate information for the nurse to tell his mother at this time? A)"Continue to watch the child, giving him aspirin and cool fluids for the fever." B)"Plan to bring the child into the physician's office today." C)"Monitor the temperature, but not to worry unless it gets above 104°F." D)"Keep the child warm and as comfortable as possible."
Ans: B Feedback:Some chemotherapy agents mask the signs of infection, so the child could be very ill. The child needs to be assessed. Aspirin is not used in children of this age because of the chance of Reye syndrome. Continuing to watch the child and giving cool fluids would be appropriate if the child was not receiving chemotherapy. The child should be dressed lightly and warm binding clothing should be avoided. In addition, for this situation, these actions are incorrect because they do not address the need for the child to be assessed.
After teaching a mother how to remove a tick from her 6-year-old boy's arm, the nurse determines that additional teaching is needed when the mother states which of the following? A)"I'll protect my fingers with a paper towel." B)"I'll grasp the tick and pull it away quickly." C)"I should put the tick in a plastic bag in the freezer." D)"I need to grasp the tick close to the child's skin."
Ans: B :Grasping the tick and pulling it away quickly would indicate the need for additional teaching. When removing a tick, the mother should use fine-tipped tweezers while protecting her fingers with a tissue, paper towel, or latex gloves. The mother should grasp the tick as close to the skin as possible and pull upward with steady, even pressure. Once removed, the mother should place the tick in a sealable plastic bag in the freezer in case the child becomes sick and identification of the tick is needed.
A pregnant woman diagnosed with syphilis comes to the clinic for a visit. The nurse discusses the risk of transmitting the infection to her newborn, explaining that this infection is transmitted to the newborn through which of the following? A)Amniotic fluid B)Placenta C)Birth canal D)Breast milk
Ans: B Feedback:The syphilis spirochete can cross the placenta at any time during pregnancy. It is not transmitted via amniotic fluid, passage through the birth canal, or breast milk.
A child is diagnosed with a helminthic infection. Which of the following would the nurse expect to be prescribed? Select all answers that apply. A)Erythromycin B)Albendazole C)Pyrantel pamoate D)Acyclovir E)Metronidazole F)Permethrin
Ans: B, C Feedback:Drugs used to treat helminthic infections include albendazole and pyrantel pamoate. Erythromycin is used to treat bacterial infections. Acyclovir is used to treat viral infections. Metronidazole is used to treat trichomoniasis. Permethrin is used to treat pediculosis.
The nurse is performing a physical examination on a 9-year-old boy who has experienced a tick bite on his lower leg and is suspected of having Lyme disease. Which assessment finding would the nurse expect to find? A)Swelling in the neck B)Confusion and anxiety C)Ring-like rash on lower leg D)Hypersalivation
Ans: C Feedback:A ring-like rash at the site of the tick bite is characteristic for Lyme disease. Swelling in the neck is a symptom of mumps. Confusion, anxiety, and hypersalivation are symptoms of rabies.
A group of nursing students are reviewing information about childhood infectious diseases. The students demonstrate understanding of this information when they identify which of the following as a common childhood exanthema? A)Mumps B)Rabies C)Rubella D)West Nile virus
Ans: C Feedback:Rubella is a common childhood exanthema. Mumps is a viral infection. Rabies is a zoonotic infection. West Nile virus is a vector-borne disease.
While obtaining a health history from a male adolescent during a well check-up, the nurse assesses his sexual behavior and risk for sexually transmitted infections. Based on the information, the nurse plans to teach the adolescent about using a condom. Which of the following would the nurse include in the teaching plan? A)"You can reuse a condom if it's within 3 hours." B)"Store your condoms in your wallet so they are ready for use." C)"Put the condom on before engaging in any genital contact." D)"Use Vaseline with a latex condom for extra lubrication."
Ans: C Feedback:When teaching an adolescent about condom use, the nurse should tell the adolescent to put the condom on before any genital contact. A new condom should be used with each act of sexual intercourse; a condom should never be reused. Condoms should be stored in a cool, dry place away from direct sunlight and never stored in wallets, automobiles, or anywhere they could be exposed to extreme temperatures. Only water-soluble lubricants should be used with latex condoms. Oil-based or petroleum-based lubricants such as Vaseline can weaken latex condoms.
A nurse is instructing a parent on how to obtain a stool culture for ova and parasites from a child with diarrhea. Which of the following would the nurse include in the teaching plan? A)"Give the child bismuth and then collect the next specimen." B)"Obtain the specimen from the toilet after the child has a bowel movement." C)"Keep the specimen from coming into contact with any urine." D)"Bring the specimen to the laboratory on the third day."
Ans: C Feedback:A stool specimen for culture must be free of urine, water, and toilet paper. Therefore, the parent needs to understand how to collect the specimen so that it does not come into contact with any these. In addition, the specimen should not be retrieved out of toilet water. Mineral oil, barium, and bismuth interfere with the detection of parasites. In such cases, specimen collection should be delayed for 7 to 10 days. Once the specimen is collected, it should be brought to the laboratory immediately.
A school-aged child with an infectious disease is placed on transmission-based precautions. Which nursing diagnosis would most likely be a priority? A)Impaired skin integrity related to trauma secondary to pruritus and scratching B)Fluid volume deficit related to increased metabolic demands and insensible losses C)Social isolation related to infectivity and inability to go to the playroom D)Deficient knowledge related to how infection is transmitted
Ans: C Feedback:Children who are placed on transmission-based precautions are not allowed to leave their rooms and are not allowed to go to common areas such as the playroom or schoolroom. Thus, they are at risk for social isolation. Impaired skin integrity, fluid volume deficit, and deficient knowledge may be appropriate but would depend on the infectious disease diagnosed.
The nurse is caring for a neonate who is suspected of having sepsis. Which of the following assessment findings would the nurse interpret as most indicative of sepsis? A)Rash on face B)Edematous neck C)Hypothermia D)Coughing
Ans: C Feedback:Hypothermia is a sign of sepsis in neonates. A rash on the face is a symptom of scarlet fever. An edematous neck is a sign of diphtheria. Paroxysmal coughing is a symptom of pertussis.
A child is diagnosed with scarlet fever. The nurse is reviewing the child's medical record, expecting which medication to be prescribed for this child? A)Ibuprofen B)Acyclovir C)Penicillin V D)Doxycycline
Ans: C Feedback:Penicillin V is the antibiotic of choice for the treatment of scarlet fever. Ibuprofen is used to treat fever. Acyclovir is used to treat viral infections. Doxycycline, a tetracycline, is the drug of choice for treating Rocky Mountain spotted fever.
The nurse is developing a teaching plan for the mother of a 4-year-old girl with cold and fever. Which of the following would the nurse include in this teaching plan? A)Keeping the child covered and warm B)Calling the doctor if the child's fever lasts more than 36 hours C)Ensuring fluid intake to prevent dehydration D)Observing for changes in alertness resulting from brain damage
Ans: C Feedback:Teaching the mother to ensure fluid intake is important because fever can cause dehydration. The child should be dressed lightly. There is no need to call the doctor unless the child's fever lasts more than 3 to 5 days or the fever is greater than 105ºF. A rapid rise to a high fever can cause a febrile convulsion, but it does not lead to brain damage.
Which of the following would be most important to include in the teaching plan for parents of a child with pinworm? A)"Seal the child's clothing in a plastic bag for at least 10 days." B)"Be sure your child wears shoes at all times." C)"Make sure the child washes his hands after using the bathroom." D)"After applying this special cream, leave it on for about 8 to 10 hours."
Ans: C Feedback:The most effective measure to prevent pinworms or a recurrence is good hand hygiene, especially after using the bathroom and before eating. Sealing the child's clothing in a plastic bag is appropriate for pediculosis capitis. Having the child wear shoes at all times is helpful in preventing hookworm. Use of a cream that remains on for a specified time is associated with scabies.
The nurse is assessing the tympanic temperature of several children. The nurse documents that the child with which temperature reading has a fever? A)99.5°F B)99.2°F C)100.0°F D)100.8°F
Ans: D Feedback:A tympanic temperature greater than 100.4°F (38°C) is defined as fever. An oral temperature of 99.5°F (greater than 37.5°C) would identify a fever. An axillary temperature of 99.1°F (greater than 37.3°C) would identify a fever.
While reviewing various studies about the use of antipyretics possibly prolonging illness, the nurse notes that there are benefits to their use for the child with fever. Which of the following would the nurse identify as the best explanation related to the benefit of antipyretics? A)They slow the growth of bacteria. B)They increase neutrophil production. C)They encourage T-cell proliferation. D)They help decrease fluid requirements.
Ans: D Feedback:Antipyretics provide symptomatic relief by increasing comfort in the child and decreasing fluid requirements, which helps to prevent dehydration. Fever has been shown to slow the growth of bacteria, increase neutrophil production, and encourage T-cell proliferation.
After teaching the parents of a child with varicella zoster, the nurse determines that the parents have understood the teaching when they state that their child can return to school at which time? A)After day 5 of the rash B)When the rash is completely healed C)Once the rash appears D)After the lesions have crusted
Ans: D Feedback:Children with chickenpox (varicella zoster) can return to school once the lesions have crusted
The nurse is preparing a plan of care for a 5-year-old boy with chickenpox. Which of the following nursing interventions should be questioned? A)Administer antipyretics as ordered. B)Keep the child's fingernails short. C)Monitor fluid intake and output. D)Provide alcohol baths as needed.
Ans: D Feedback:Treatments such as sponging the child with alcohol or cold water are not appropriate interventions for fever management. Rather, the nurse would use tepid sponge baths and cool compresses. Administering antipyretics, keeping the child's fingernails short, and monitoring intake and output are appropriate
The nurse is caring for children who are receiving IV therapy in the hospital setting. For which of the following children would a central venous device be indicated? A) A child who is receiving an IV push B) A child who is receiving chemotherapy for leukemia C) A child who is receiving IV fluids for dehydration D) A child who is receiving a one-time dose of a medication
B) A child who is receiving chemotherapy for leukemia
The nurse is preparing to administer an intramuscular injection to an 8-month-old infant. Which site would the nurse select? A) Rectus femoris B) Vastus lateralis C) Dorsogluteal muscle D) Deltoid
B) Vastus lateralis
The nurse is preparing a 5-year-old for a radiograph. Which of the following would be the best communication to prepare the child for the procedure? A) "We are going to take some x-rays of your body." B) "We need to look inside at some of your organs." C) "X-rays are not painful; you won't feel a thing." D) "We are going to use a big camera to take pictures inside your body."
D) "We are going to use a big camera to take pictures inside your body."
The nurse is preparing to administer oral ampicillin to a child who weighs 40 kg. The safe dose for children is 50 to 100 mg/kg/day divided in doses administered every 6 hours. What would be the low single safe dose and high single safe dose per day for this child? A) 50 to 100 mg per dose B) 100 to 500 mg per dose C) 500 to 1,000 mg per dose D) 1,000 to 5,000 mg per dose
C) 500 to 1,000 mg per dose
The mother of a 15-month-old child is questioning the nurse about the need for the hepatitis B vaccination. Which of the following comments provides the most compelling reason for the vaccine? A) "The most common side effect is injection site soreness." B) "This is a recombinant or genetically engineered vaccine." C) "Immunizations are needed to protect the general population." D) "This protects your child from infection that can cause liver disease."
D
The nurse is providing anticipatory guidance to an obese teenager. Which of the following interventions would be most likely to promote healthy weight in teenagers? A) Make the focus of the program weight centered. B) Begin directly advising children about their weight at age 6. C) Focus physical activity on competitive sports and activities. D) Obtain nutritional histories directly from the school-age child and adolescent.
D
The nurse is supporting an 8-year-old child who is having blood specimens drawn. Which method would be least appropriate to use for distraction? A) "Squeeze my hand as tight as you can." B) "Look at how many dots there are on the ceiling." C) "Count with me slowly from 1 to 20." D) "It's okay to scream if it hurts."
D) "It's okay to scream if it hurts."
The nurse is caring for a child who is receiving total parenteral nutrition (TPN) for failure to thrive. Which of the following nursing actions might the nurse take to prevent complications from this therapy? A) Adhere to clean technique when caring for the catheter and administering TPN. B) Ensure that the system remains an open system at all times. C) Secure all connections and open the catheter during tubing and cap changes. D) Use occlusive dressings and chlorhexidine-impregnated sponge (Biopatch) dressings.
D) Use occlusive dressings and chlorhexidine-impregnated sponge (Biopatch) dressings.
