Final

Which intervention should the nurse implement when using an oxyhood to assist a child's respirations?

Ensure a high rate of flow of oxygen.

Which intervention is most important when using an infusion pump to delivery IV fluid therapy to a toddler?

Ensure that the catheter is in the vein.

Which guideline is recommended when administering medications to children?

When administering liquids, use the smallest syringe possible to ensure accuracy.

A mother whose infant is diagnosed with failure to thrive (FTT) asks the nurse what causes this condition and how it is treated. What is the nurse's best response?

Most often, FTT has a psychosocial rather than congenital physical cause.

The nurse is collecting a urine specimen from an 18-month-old male client. Which guideline is recommended for this procedure?

Apply the bag to the penis, sealing it from the top to the bottom.

Two cases of lice are identified. Which intervention should the school nurse implement to prevent the spread of pediculosis to the entire class?

Ask students not to share their hats or combs.

The nurse is providing support for a client who just finished a hemodialysis session. Which patient symptom is considered to be a complication of hemodialysis?

Cardiac arrhythmias and angina from fluid loss

The nurse providing care to children in a hospital pediatric ward discusses safety with newly hired UAPs. Which guideline ensures safety for these clients?

When taking a child's temperature, consider his or her ability to cooperate.

The mother of a 4-month-old infant asks the nurse about the right time to start solid food for the baby. Which should the nurse tell the mother?

When the baby starts sitting without any support

A child of European descent is diagnosed with celiac disease. What food should the parents be instructed to remove from their child's diet?

Whole wheat bread

The nurse is reinforcing teaching to a client who is preparing to perform intermittent self-catheterization at home. Which information by the nurse is inappropriate?

Wear a urinary incontinence pad if away from home.

Which is the average range of pulse or respiration for an infant?

Pulse: 100 to 160

The nurse is providing care for a patient who has undergone placement of a suprapubic catheter. Which postprocedure nursing care is avoided?

Change the catheter with sterile technique daily.

A nurse is calculating a client's fluid intake over the past 8 hr. The client had one 8-oz cup of coffee, 3 oz of juice, and 12 oz of soda. The client's water pitcher had 800 mL and 200 mL remain. The client also had IV fluids infusing at 40 mL/hr via an IV pump. How many mL should the nurse document as the client's total intake for the shift?

1610

Which guideline ensures safety when applying a restraint on a child?

A physician's order is required for a restraint.

A school-aged child is diagnosed with the common cold. The parent is concerned that the child did not receive an antibiotic and wants to know how the child can get rid of the cold without it. What is the best response by the nurse?

A virus causes a cold and antibiotics are used for bacterial infections.

Which restraint option is best for preventing a child from pulling on a nasogastric tube?

Mitt or glove

A 19-year-old patient reports flank pain and scanty urination. The nurse notices periorbital edema, and the urinalysis reveals white blood cells, red blood cells, albumin, and casts. Which question will provide important information for the nurse to include in data collection?

"Have you had any type of strep infection recently?"

The nurse is reviewing the laboratory results for a patient. Which question does the nurse ask the patient if the creatinine level is elevated?

"How much do you exercise?"

The nurse is testing the urine pH for a patient in the HCP's office. The test indicates a pH of 7.0. Which question does the nurse ask the client?

"Are you following a vegetarian diet?"

The nurse is reinforcing teaching provided to a patient about caring for a new arteriovenous (AV) fistula in the left arm for dialysis. Which patient statements indicate correct understanding? (Select all that apply.)

"Do not sleep on my arm.", "Wear loose clothing on my left arm.", "Avoid carrying heavy things with my left arm."

Which head-to-chest ratio is normal for children?

The chest and head are about equal for ages 1 to 2 years.

A nurse is completing the 8-hr I&O record for a client who consumed 4 oz of clear soda, 1 piece of toast, 12 oz of water, 1 cup of fruit-flavored gelatin, and 1/2 cup of chicken broth. The client also received 300 mL of 0.9% sodium chloride IV. The nurse should record how many mL of intake on the client's record? (Round the answer to the nearest whole number.)

1140

The nurse is catheterizing a patient after voiding to determine the amount of residual urine in the bladder. What should the nurse consider as being the normal amount of urine within the bladder after urination?

25 mL

A child is visiting a friend who has several dogs and cats and begins wheezing, has difficulty breathing, and has chest tightness. The parents bring the child to the ER and explain the symptoms to the nurse. This assessment data supports which medical diagnosis?

Acute asthma

A nurse is caring for a child with a fever of 102°F. What interventions should the nurse perform when caring for this child?

Attempt to keep the child from crying.

The nurse is preparing a patient for a cystectomy and the creation of a continent urinary diversion. For which reason does the nurse identify creation of this type of diversion?

Convenience for the patient

The nurse is collecting information from an older adult patient in the health care provider's (HCP) office. The patient reports frequent urination. Which effect of aging does the nurse recognize?

Decreased bladder size and muscle tone

The nurse enters a hospitalized child's hospital room and finds that the child is sitting quietly in bed and appears very sad. The child is sucking his thumb, and clutching his blanket. What stage of separation anxiety is this child displaying?

Despair

Which diagnostic finding supports a diagnosis of rheumatic fever?

Elevated erythrocyte sedimentation rate (ESR)

An older male patient expresses frustration at need to urinate often, dribbling of urine, and feelings of inability to empty his bladder. Which suggestion by the nurse is most helpful to the patient?

Encourage an appointment with a urologist.

The nurse is collecting data on a patient who experienced a sport injury to the lower back area. Which finding will cause the nurse greatest concern?

Flank edema and bloody urine

Which is typically the first immunization received by a newborn?

Hepatitis B

The nurse is providing care for a patient who is on fluid restrictions due to renal failure. The patient's intake & output (I&O) should be carefully measured. Which substance does the nurse exclude from the intake total?

Mashed potatoes and creamed corn

A nurse is measuring the head and chest circumference of a child. Which guideline is recommended for these procedures?

Measure the occipitalfrontal circumference of the head for children up to 3 years of age.

The nurse is caring for a child who has a fractured femur. On examination, the nurse notices other bruises and wounds in varying stages of healing and suspects child abuse. What is the appropriate nursing intervention in this situation?

Notify the appropriate authorities.

The nurse is obtaining data from a child who will be having a surgical procedure this morning. The nurse observes the child has a cough, runny nose, and temperature of 100°F. What is the priority action by the nurse?

Notify the surgeon of the findings

A 7-year-old child is diagnosed with chickenpox. Which eruption is the first to be seen in chickenpox?

Papules

A nurse is performing a physical assessment on a 3-year-old boy. The mother answers "no" when asked if the child is up to date with vaccinations. The child presents with slight fever and spasms of coughing that make a "whooping" sound. The mother said that occasionally the child vomits after coughing so hard. What disease would the nurse suspect?

Pertussis

The nurse is providing care for a patient who recently had an access for hemodialysis placed. Which important action does the nurse take with this patient?

Refrains from drawing blood or placing IV lines in the arm in which access was placed

The nurse understands that a major function of the kidneys is to remove potentially toxic waste products from the blood. Which function is inaccurate?

Regulate blood pressure through the conservation of minerals.

The nurse is taking the vital signs of a toddler who is being admitted to the hospital. Which vital sign should the nurse assess first?

Respirations

The nurse is taking the vital signs of children of different ages on a pediatric unit of a hospital. Which of guideline is recommended for this procedure?

Take an oral or tympanic temperature for children older than 6 years.

A child at the healthcare facility is scheduled to undergo surgery. Which intervention should the nurse implement immediately before the surgery?

Take and record vital signs and weight.

A nurse is caring for a 3-year-old child placed in a splint brace for correcting developmental dysplasia. Which nursing consideration should the nurse keep in mind when caring for the client?

Take precautions when handling the child.

Which should the nurse keep in mind when recording the blood pressure of a 10-year-old child?

The cuff should cover approximately two-thirds of the upper arm

The nurse is providing care for a patient with a diagnosis of kidney disease. The patient's last laboratory result indicates metabolic acidosis. Which kidney activity does the nurse recognize for the condition?

The kidneys are unable to excrete hydrogen ions.

The nurse is providing care for a patient scheduled for diagnostic studies of the gastrointestinal system using contrast medium. Which finding in the patient's medical history warrants the nurse contacting the HCP?

The patient has a history of renal dysfunction.

The nurse is providing care for a patient with a thoracic spinal cord injury. For which reason does the nurse understand the presence of a suprapubic catheter?

The patient is unable to detect the need to urinate.

A nurse is calculating the total fluid intake for a client during a 4-hr period. The client consumed 1 cup of coffee, 4 oz of orange juice, 3 oz of water, 1 cup of flavored gelatin, 1 cup of tea, 5 oz of broth, and 3 oz of water. The nurse should record how many mL of intake on the client's record? (Round the answer to the nearest whole number.)

1170

A nurse is calculating a client's intake and output for an 8-hr shift. The client's intake included 1,000 mL 0.9% sodium chloride IV solution, one 6-oz cup of coffee, 6 oz of water, one 180-mL bowl of soup, 3 oz of flavored gelatin, and 3 oz of ice cream. How many mL should the nurse document as the client's total intake for the shift?

1720

A nurse is calculating the fluid intake for an infant at the end of an 8-hr shift. For oral intake, the infant had 10 mL of medication, 3 oz of formula, and 2 oz of juice. In addition, the infant had IV fluid infusing at 20 mL/hr via an IV pump. The nurse should record how many mL of intake on the client's record? (Round the answer to the nearest whole number.)

320

A patient is to receive 1,600 mg of sevelamer (Renagel) orally with meals. Renagel 400-mg tablets are available. How many tablets should the nurse give?

4

A nurse is calculating the total fluid intake for a client during an 8-hr period. The client had an IV bolus of 150 mL and consumed 4 oz of juice, 6 oz of hot tea, 100 mL of water, and 8 oz of clear broth. The nurse should record how many mL of intake on the client's record? (Round the answer to the nearest whole number.)

790

Which pregnant mother is at greatest risk for having a child with Down syndrome?

A 45-year-old mother with 4 children

Which patient will the nurse consider to be at greatest risk for cancer of the kidney?

A 60-year-old male with a 20-year history of smoking and works in a chemical laboratory

Which child has been diagnosed with a disease that requires Contact Precautions?

A baby with RSV and no productive cough

The nurse is making a visit to the home of a patient with functional incontinence. Which observation indicates that teaching about the disorder has been effective?

Patient wearing sweat pants

Which form of leukemia is the most commonly diagnosed in children under 15 years of age?

Acute lymphoid leukemia (ALL)

The nurse is performing a physical assessment of a teenager. What unique focus of adolescent care should the nurse keep in mind when caring for adolescents?

Adolescents may voice individual concerns and should be talked to separately.

A nurse is assisting with a client health history for a 5-year-old boy being admitted to the hospital for surgery. Which of guideline is recommended for gaining the child's cooperation?

Allow the child to sit in the caregiver's lap for as much of the interview as possible.

A 4-year-old child is postoperative following surgery to repair a cleft lip (cheiloplasty). Which intervention should be performed immediately after surgery?

Apply an elbow restraint.

A patient has completed a dialysis session. The nurse notes bleeding from the patient's vascular access in the left arm. Which of the following is the nurse's first action?

Apply pressure to access site

A 3-month-old infant is diagnosed with spina bifida. Which information should be included in parent teaching?

Avoid rubber toys.

The nurse is providing postoperative care for a patient with a newly formed ileal conduit for a diagnosis of cancer. Which factor regarding the patient's surgery does the nurse identify as incorrect?

Bladder continence will develop after healing.

The nurse caring for hospitalized children knows that these children need protection from contagious diseases. What infection control measures are recommended in this situation?

Change disposable gowns at least once a shift.

The nurse is teaching new parents how to bathe their infants through demonstration. Which teaching point would the nurse include?

Cleanse eyes first with two cotton balls and clear water, cleansing from inner to outer canthus.

The nurse is reinforcing teaching provided to a patient with a history of calcium oxalate kidney stones. The nurse recognizes that teaching has been effective if the patient avoids which foods? (Select all that apply.)

Cocoa, spinach, peanuts

During a physical assessment, the nurse suggests to the parents that a preschooler be given the Denver-II Developmental Screening Test. Which area would this test assess?

Cognitive development

It is appropriate to take an oral temperature for a child experiencing which condition?

Diarrhea

The nurse is providing education to the mother of a toddler who is brought to the pediatrician for a well visit. What would be a focal point for client education based on the child's developmental level?

Discipline and limit setting

The nurse is preparing to reinforce teaching to a patient newly diagnosed with PKD. Which information does the nurse include? (Select all that apply.)

Grape-like cysts will replace normal, functioning structures. Initial symptoms are dull heaviness in the flank area and hematuria. Patients are at risk for brain aneurysms and diverticulosis in the colon. Disease is likely to require additional treatment for hypertension and UTIs.

The nurse is providing care for a patient scheduled for surgery for the formation of an orthotopic bladder substitution. Which patient teaching is important for the nurse to review during the patient's recovery?

How to perform catheterization

The formation of urine is a critical physiological function. The nurse is aware that multiple processes are involved. Which process does the nurse recognize as not part of the formation of urine?

Micturition

A nurse is examining an infant of Asian descent who presents with irregular dark, blue-green areas generally found on the lower back. The shapes have regular edges. What condition does the nurse suspect?

Mongolian spots

The nurse is reinforcing teaching about the most serious side effect of peritoneal dialysis with a patient scheduled for the first treatment. Which side effect stated by the patient indicates correct understanding?

Peritonitis

The school nurse working with adolescents recognizes that adolescents are often embarrassed about talking about their health problems. Which teaching strategy would be helpful for this age group?

Placing pamphlets regarding adolescent concerns in a brochure rack.

A nurse is required to administer a suppository to a child to promote bowel movements. Which should the nurse do to effectively administer the suppository?

Press the anal sphincter gently to hold the suppository.

The nurse is reviewing the results of a patient's urinalysis. Which components does the nurse identify as being abnormal in urine? (Select all that apply.)

Protein, RBCs

A child is admitted to the healthcare facility for surgery following a fracture. The child is aggressive and refuses to comply with the staff of the facility. Which phase of separation anxiety is the child going through?

Protest

A patient shares a long-standing problem of urinary incontinence with the nurse. Which intervention does the nurse recognize as taking priority?

Providing caring support to the patient

A nurse is teaching new parents about the causes of sudden unexpected infant death (SUID) and sudden infant death syndrome (SIDS) and interventions to help prevent these deaths. Which information about SUID and SIDS is accurate? Select all that apply.

SIDS has been linked to sleeping in a prone position.SUID can be caused by metabolic disorders.

The nurse is caring for a postoperative patient who is receiving 0.9% normal saline intravenously at 125 mL/hour, morphine intravenously for pain control, and gentamicin (Garamycin) intravenously every 8 hours for 24 hours. The patient is allergic to iodine. Morning labs are white blood cell 8,500, hemoglobin 12.4 g/dL, and serum creatinine 2.2 mg/dL. Which of these findings is a priority for the licensed vocational nurse to report to the registered nurse?

Serum creatinine 2.2 mg/dL

The nurse is providing care for a patient admitted with severe flank pain identified as renal colic. Urinalysis is positive for microscopic hematuria. Which nursing intervention is most important for the nurse to implement?

Strain urinary output and observe for stones.

A mother brings her 9-year-old daughter to the community health clinic for a sore throat that began several days ago. The child reports a lump in her throat and soreness all over her body. On examination, the nurse documents white patches on the tonsils. What disease would the nurse suspect?

Strep

The nurse is visiting a patient who performs peritoneal dialysis at home. The nurse is evaluating the patient's technique and environment. Which situation is least likely to cause the nurse concern?

The patient verbally expresses symptoms to report to the HCP.

The nurse is providing care for older adult clients in an extended care facility. Which patient will the nurse monitor most closely for symptoms of urosepsis?

The patient who has an indwelling catheter for a urinary tract infection (UTI)

The nurse is assisting with a venipuncture on an infant. What is the preferred site for this procedure?

Thigh

A child who ingested a poison is treated with gastric lavage. What factor will determine whether the client is then admitted to the hospital?

Time between ingestion of poison and lavage

A child presents in the ER with symptoms of Reye syndrome. Which is a suspected etiology of this disease?

Use of aspirin during viral illness

During the online lecture, in part 2 of the Pediatric PowerPoint, what was one of the congenital cardiac defect I told you I was born with and had corrective surgery for when I was 10 years old?

atrial septal defect pulmonary stenosis ASD

The nurse is providing care for a patient admitted for a suspected kidney infection (pyelonephritis). Which area of the body does the nurse expect the patient to identify as a source of pain?

bilateral flanks

A patient with chronic kidney disease has a potassium level of 6 mEq/L Th nurse should monitor this patient for which of the following?

cardiac arrhythmias

The nursing diagnosis of Excess Fluid Volume is make for a patient with chronic kidney disease. Which of the following data is most important for the nurse to collect for this patient based on the nursing diagnosis?

daily weight

A patient is admitted with symptoms of recent weight gain, pitting edema of the feet, jugular vein distention, and lung crackles. Which of the following nursing diagnoses is most appropriate for this patient's plan of care?

fluid volume excess

Following a urostomy (ileal conduit), the nurse notes the presence of mucus in the patient's urostomy bag. Which of the following action should the nurse take?

recognize this as a normal occurrence

A patient's urinalysis results are: urine: cloudy white blood cells (WBCs) 100+/hpf red blood cells (RBC) 4/hpf bacteria: moderate amount (4+) nitrite: positive specific gravity: 1.025 What should the nurse recognize these findings indicate?

urinary tract infection