HESI PA Peds review
A mother is carrying in her 3-year-old to the emergency department (ED) screaming, "I think my baby swallowed a bottle of Tylenol." What is the nurse's next action? A. Notify the health care provider in the ED. B. Take the child's vital signs. C. Start an IV. D. Ask the mother for the bottle containing the Tylenol.
B. Take the child's vital signs.
The health care provider prescribes digoxin 0.05 mg/kg/day in two equally divided doses. The child' weight is 18 pounds. How many mg will the nurse administer in one dose? _____ (Round to the nearest tenth.)
0.2 mg per dose
The nurse is providing care for a child newly admitted in a sickle cell crisis. In reviewing the admission prescriptions, which prescription is concerning and the nurse needs to confirm with the health care provider? A. Meperidine 15 mg IV every 4 hours, around the clock for pain. B. Hydrate with 2000 mL of oral fluids over the next 6 hours. C. Place cold compresses to affected joints for 15 minutes every 4 hours. D. Raise the head of the bed 20 to 30 degrees and dim the lights.
A. Meperidine 15 mg IV every 4 hours, around the clock for pain.
A nurse is caring for a 3-year-old child newly admitted to the emergency department (ED) with labored respirations, a continuous respiratory stridor, sternal retractions with inspiration, and restlessness. What immediate actions will the nurse take for this child? (Select all that apply.) A. Place the head of the bed up 45 degrees. B. Assess the child's oxygen saturation. C. Assess for exposure to bacterial meningitis. D. Instruct parents to use a cool air vaporizer. E. Assess for pallor and cyanosis.
A. Place the head of the bed up 45 degrees. B. Assess the child's oxygen saturation. E. Assess for pallor and cyanosis.
A 3-month-old infant returns from surgery with elbow restraints and a Logan bow over a cleft lip suture line. Which action should the nurse take to maintain suture line integrity during the initial postoperative period? A. Place the infant upright in an infant seat position. B. Provide mittens with the use of elbow restraints. C. Use soft rubber catheters for nasal suctioning D. Apply water-soluble lubricant to the suture line.
A. Place the infant upright in an infant seat position.
A 2-year-old child with trisomy 21 (Down syndrome) is brought to the clinic for a routine evaluation. Which assessment finding suggests the presence of a common complication often experienced by those with Down syndrome? A. Presence of a systolic murmur B. New onset of patchy alopecia C. Complaints of long bone pain D. Recent projectile vomiting
A. Presence of a systolic murmur
A nurse is conducting a community teach to a group of parents with toddlers. What information will the nurse include in the presentation? (Select all that apply.) A. Program the number for poison control in all cellphones. B. Keep medications in a locked cabinet. C. Place cleaning chemicals out of reach. D. Avoid strawberries and blueberries. E. Do not allow your children to pay with balloons.
A. Program the number for poison control in all cellphones. B. Keep medications in a locked cabinet. E. Do not allow your children to pay with balloons.
What is the best position for the nurse to place a newborn with a meningocele? A. Prone B. Left side lying C. Right side lying D. Supine
A. Prone
The nurse is teaching an adolescent girl with scoliosis about a Milwaukee brace that her health care provider has prescribed. Which instruction should the nurse provide to this client? A. Remove the brace 1 hour each day for bathing only. B. Remove the brace only for back range-of-motion exercises. C. Wear the brace against the bare skin to ensure a good fit. D. Wearing the brace will cure the spinal curvature.
A. Remove the brace 1 hour each day for bathing only.
The nurse is assessing a 3-year-old presenting to the emergency department with agitation, a cherry red and edematous epiglottis, and a high fever. What focuses assessments will the nurse include in this child's plan of care? (Select all that apply.) A. Respiratory rate B. Use of accessory muscles when breathing C. Babinski reflex D. Bowel sounds E. Breath sounds
A. Respiratory rate B. Use of accessory muscles when breathing E. Breath sounds
The in-patient nurse is caring for a child with leukemia. The parents are asking for help with meal selection for their child. What items will the nurse recommend? (Select all that apply.) A. Scrambled eggs B. Creamed corn C. Spaghetti and meatballs D. Macaroni and cheese E. Honey-based granola bars
A. Scrambled eggs B. Creamed corn D. Macaroni and cheese
A child comes to the school nurse complaining of itching. Further assessment reveals that the child has impetigo. What action should the nurse take? A. Send the child home with the parents to see the health care provider before returning to school. B. Send the child home with the parents and report this to the health department. C. Cover the lesion with a dry gauze dressing and send the child back to class. D. Wash the lesion with antimicrobial soap, air-dry, and send the child back to class.
A. Send the child home with the parents to see the health care provider before returning to school.
The nurse is performing discharge teaching to the parents after the birth of their child with a cleft palate. When planning for the timing of the cleft palate repair, what developmental milestones will the infant exhibit? (Select all that apply.) A. Sitting up with props B. Walks holding onto furniture C. Rolling over from front to back D. Knows familiar faces E. Finds hidden objects
A. Sitting up with props C. Rolling over from front to back D. Knows familiar faces
Which assessment findings should the nurse expect when caring for a child with cystic fibrosis? (Select all that apply.) A. Steatorrhea B. Obesity C. Foul-smelling stools D. Delayed growth E. Pulmonary congestion
A. Steatorrhea C. Foul-smelling stools D. Delayed growth E. Pulmonary congestion
The nurse assesses a newborn during an initial feeding of formula and notes choking, coughing, and bluish lips. What is the nurse's next action? A. Stop the feeding. B. Firmly tap the newborn's back. C. Look for blue hands and feet. D. Place the infant in a bassinette raised 30 degrees.
A. Stop the feeding.
Upon initial assessment of a newborn, the nurse palpates the infant's mouth and feels an incomplete closure of the soft palate. What other focused assessments will the nurse include in the newborns plan of care? (Select all that apply.) A. Suck B. Swallow C. Calorie intake D. Daily weight E. Moro reflex F. Plantar creases
A. Suck B. Swallow C. Calorie intake D. Daily weight
A nurse in the emergency department is working with a nursing student. Which student action will the nurse need to correct when caring for a child with epiglottitis? A. Take an oral temperature. B. Place the pulse ox on the earlobe. C. Take away oral fluids from the bedside. D. Place cool mist oxygen therapy.
A. Take an oral temperature.
The nurse assigns an unlicensed assistive personnel (UAP) to provide morning care to a newly admitted child with bacterial meningitis. What is the most important instruction for the nurse to review with the UAP? A. Use designated isolation precautions. B. Keep the lighting in the room dim. C. Allow the parents to assist with care. D. Report any pain that the child experiences.
A. Use designated isolation precautions.
A child is being sent home with a prescription for liquid iron. Which statements indicate to the nurse that the mother understands the discharge instructions? (Select all that apply.) A. "This medication will work in about a week." B. "I will have my child drink this with a straw." C. "Teeth brushing will follow the administration." D. "I will watch for green, liquid stools." E. "I will give this on an empty stomach."
B. "I will have my child drink this with a straw." C. "Teeth brushing will follow the administration." E. "I will give this on an empty stomach."
The nurse is providing care to a newborn with hypospadias. Which parent statement indicates the nurse's teaching has been successful? A. I will not be able to beast feed my baby at all. B. A circumcision will not be performed before discharge. C. We will need to undergo genetic testing for future children. D. I will call the doctor if my baby's heart rate is above 150.
B. A circumcision will not be performed before discharge.
A mother reports to the clinic nurse persistent nighttime bed wetting for her 6-year-old child. What focused assessments will the nurse include in the child's initial evaluation? (Select all that apply.) A. Have the mother conduct a 48-hour diet recall. B. Determine the amount of fluid intake after 1800. C. Ask if the child urinates just before bedtime. D. Ask about the onset of the bedwetting. E. Obtain a clean catch urine sample. F. Ask if the child has started riding a bicycle.
B. Determine the amount of fluid intake after 1800. C. Ask if the child urinates just before bedtime. D. Ask about the onset of the bedwetting. E. Obtain a clean catch urine sample.
The nurse is teaching the sick day rules to the parents of child with insulin-dependent diabetes. Which instructions will the nurse include in the plan? (Select all that apply.) A. Restrict fluids to no more than 1000 mL/day. B. Encourage the child to eat a regular meal plan. C. Test for ketones in the urine with each void. D. Cut the insulin by 50% with each scheduled dose. E. Encourage rest and restful activities.
B. Encourage the child to eat a regular meal plan. C. Test for ketones in the urine with each void. E. Encourage rest and restful activities.
The nurse checks the fluid from the nose of the client newly admitted to the emergency room after a motor vehicle accident. Which positive finding would be most concerning to the nurse? A. Protein B. Glucose C. Blood D. pH 7.4
B. Glucose
The nurse is providing care for an infant started on digoxin. The am assessment of this child included poor feeding and vomiting, and a heart rate of 96 beats/min. The am digoxin level is 2.3 ng/mL. What is the nurse's next action? A. Hold the am dosage of digoxin. B. Notify the health care provider. C. Assess for a dysrhythmia. D. Administer 30 mL of sterile water.
B. Notify the health care provider.
An infant is receiving digoxin for congestive heart failure. The apical heart rate is assessed at 80 beats/min. What action should the nurse take first? A. Call for a portable chest radiograph. B. Obtain a therapeutic drug level. C. Reassess the heart rate in 30 minutes. D. Administer digoxin immune Fab stat.
B. Obtain a therapeutic drug level.
How will the nurse plan to position a child with left sided pneumonia? A. On the child's right side B. On the child's left side C. Head of the bed up at a 90 degrees angle D. Prone, with pillows placed bilaterally
B. On the child's left side
The nurse is performing a newborn assessment. A clicking sensation is noted when abducting the child's thigh and placing gentle pressure over the greater trochanter. How will the nurse document this finding? A. Positive Barlow's test B. Positive Ortolani maneuver C. Positive Homan's sign D. Positive Galeazzi's sign
B. Positive Ortolani maneuver
Following the reduction of an incarcerated inguinal hernia, a 4-month-old boy is scheduled for surgical repair of the inguinal hernia. Under which circumstance should the parents notify the health care provider prior to surgery? A. Crying that is unrelieved by comforting measures B. Presence of an inguinal bulge after gentle palpation C. Refusal to take oral feedings D. Straining during defecation
B. Presence of an inguinal bulge after gentle palpation
For the child admitted to the emergency department with an elevated blood glucose level, the nurse will anticipate an order for which kind of insulin? A. Levemir B. Regular C. NPH D. Lantus
B. Regular
A 6-month-old infant is admitted to the postanesthesia care unit with elbow restraints in place. An endotracheal tube is in place connected to a ventilator, but the child will be extubated soon following recovery from anesthesia. Which action should the nurse include in the child's postoperative care? A. Keep restraints on at all times to prevent unplanned extubation. B. Remove restraints one at a time and provide range-of-motion exercises. C. Remove all restraints simultaneously and provide play activities. D. Document the reason for application of the restraints every 72 hours.
B. Remove restraints one at a time and provide range-of-motion exercises.
Which vital sign is most important to assess in the 6-year-old child brought to the clinic with reddened, open, and oozing skin lesions? A. Pulse B. Temperature C. Respirations D. Blood pressure
B. Temperature
A child presents to the emergency department with vomiting and diarrhea for 36 hours. Which finding is most concerning to the nurse? A. No tears when crying B. Urine specific gravity of 1.035 C. Pink lips and gums D. Temperature of 99.2°F/37.3°C
B. Urine specific gravity of 1.035
The nurse should teach the parents of a child with a cyanotic heart defect to perform which action when a hypercyanotic spell occurs? A. Place the child's head flat, with the knees on pillows above the level of the heart. B. Have the child lie on the right side, with the head elevated on one pillow. C. Allow the child to assume a knee-chest position, with the head and chest slightly elevated. D. Encourage the child to sit up at a 45-degree angle, drink cold water, and take deep breaths.
C. Allow the child to assume a knee-chest position, with the head and chest slightly elevated.
A child breaks out with varicella infection (chickenpox) while hospitalized for a minor surgical procedure. Which action should the nurse take first? A. Place a mask on the child before transporting the child outside the room. B. Immunize exposed family members with the varicella vaccine. C. Place the child in strict isolation to prevent an outbreak on the unit. D. Determine which staff have had varicella before making assignments
C. Place the child in strict isolation to prevent an outbreak on the unit.
A child presents again to the school nurse with dyspnea, wheezing, diaphoresis, and deep dark-red lips. What is the next nursing action? A. Call the child's parents. B. Call 911. C. Ask, "Do you have your inhaler?" D. Ask, "Did you play outside today?"
C. Ask, "Do you have your inhaler?"
A 3-week-old infant is referred to an orthopedic clinic because the pediatrician heard a click when flexing the child's right hip during a routine physical examination. Which risk factor is most closely related to developmental hip dysplasia? A. Vertex delivery B. Male gender C. Breech presentation D. Second-born child
C. Breech presentation
The nurse expects a 2-year-old child to exhibit which behavior? A. Build a house with blocks. B. Ride a small tricycle 6 feet. C. Display possessiveness with toys. D. Look at a picture book for 15 minutes.
C. Display possessiveness with toys.
The nurse is reviewing laboratory values of a child just started on furosemide. The child's serum potassium level is 4.2 mEq/L. What is the nurse's next action? A. Notify the health care provider. B. Hold the next dose of furosemide. C. Document the finding in the nurse's notes. D. Assess the child for cramping and confusion.
C. Document the finding in the nurse's notes.
A 7-month-old infant with a rotavirus causing severe diarrhea is admitted for treatment. Which action should the nurse take first? A. Obtain a scale to weigh the infant's diapers. B. Instruct the mother to offer Pedialyte regularly. C. Insert an intravenous (IV) line and begin IV fluids. D. Obtain a stool specimen for analysis.
C. Insert an intravenous (IV) line and begin IV fluids.
A newborn whose mother is HIV-positive is scheduled for the first follow-up assessment with the nurse. If the child is HIV-positive, which initial symptom will the child most likely exhibit? A. Shortness of breath B. Joint pain C. Persistent cold D. Organomegaly
C. Persistent cold
A child breaks out with varicella infection (chickenpox) while hospitalized for a minor surgical procedure. Which action should the nurse take first? A. Place a mask on the child before transporting the child outside the room. B. Immunize exposed family members with the varicella vaccine. C. Place the child in strict isolation to prevent an outbreak on the unit. D. Determine which staff have had varicella before making assignments.
C. Place the child in strict isolation to prevent an outbreak on the unit.
The nurse is caring for a child with intussusception who is scheduled for a barium enema prior to a surgical procedure. Which action should the nurse take first? A. Evacuate the bowel of impacted feces. B. Administer magnesium sulfate. C. Place the child on a clear liquid diet. D. Assess the stool for white color.
C. Place the child on a clear liquid diet.
Which nursing action will the nurse take first for the child known to have diabetes admitted to the emergency room? A. Start an IV. B. Administer orange juice. C. Take a blood glucose reading. D. Dipstick urine for ketones.
C. Take a blood glucose reading.
In making the initial assessment of a 2-hour-old infant, which finding should lead the nurse to suspect a congenital heart defect? A. Irregular respiration and heart rate B. Gagging C. Blue feet and hands D. Diminished femoral pulses
D. Diminished femoral pulses
A 4-year-old child has cystic fibrosis. Which stage of Erikson theory of psychosocial development is the nurse addressing when teaching inhalation therapy? A. Autonomy B. Industry C. Trust D. Initiative
D. Initiative
Which preoperative nursing action should be included in the plan of care for an infant with pyloric stenosis? A. Monitor for signs of metabolic acidosis. B. Estimate the quantity of diarrhea stools. C. Place in a supine position after feeding. D. Observe for projectile vomiting.
D. Observe for projectile vomiting.
The nurse is conducting meal planning for a child scheduled for discharged after treatment for acute glomerulonephritis. What foods are appropriate for this child? (Select all that apply.) A. Lean beef B. Chicken without the skin C. Brown rice D. Movie-style popcorn E. Regular canned green beans F. Carrots
A. Lean beef B. Chicken without the skin C. Brown rice F. Carrots
The nurse is providing care to an infant is recovering from a shunt placement for hydrocephalus. Which actions will the nurse include in the immediate postoperative care of this infant? (Select all that apply.) A. Measure head circumference. B. Place infant on the operative side. C. Assess neurological signs every hour. D. Keep the infant flat. E. Stimulate the infant to cry every hour.
A. Measure head circumference. C. Assess neurological signs every hour. D. Keep the infant flat.
A woman is being discharged following the birth of her second child. Her first child died at 6 weeks of age because of sudden infant death syndrome (SIDS). The mother tells the nurse that she is fearful that this infant will also develop SIDS. What is the nurse's best response? A. "You can prevent SIDS if your baby sleeps on the side or back. You will have to monitor the baby carefully." B. "The fear of losing another child to SIDS is very realistic. Have you thought about what support you may need?" C. "An apnea monitor will alert you if the baby stops breathing. This will give you the peace of mind that you need." D. "My neighbor's baby died of SIDS last year and she went to a SIDS support group. That really helped her."
B. "The fear of losing another child to SIDS is very realistic. Have you thought about what support you may need?"
Prophylactic antibiotics are prescribed for a child who has mitral valve damage. The nurse should advise the parents to give the antibiotics prior to which occurrence? A. Adjustment of orthodontic appliances or braces B. Loss of deciduous teeth (baby teeth) C. Urinary catheterization D. Insect bites
C. Urinary catheterization
The nurse is evaluating the teaching given to the parents of a child with glomerulonephritis. Which parent statement will the nurse need to correct? (Select all that apply.) A. Weigh at the same time every day. B. Use the same scale for daily weights. C. Wait 2 to 3 days to report rusty-brown urine. D. See the health care provider if a sore throat develops. E. Report facial edema that occurs in the evening.
C. Wait 2 to 3 days to report rusty-brown urine. E. Report facial edema that occurs in the evening.
The nurse is taking the family history of a 2-year-old child with atopic dermatitis (eczema). Which statement by the mother is most important in formulating a plan of care for this child? A. "Our first child was born with a cleft lip." B. "We are very careful not to get sunburns in our family." C. "My first child sometimes got a diaper rash." D. "My husband and our daughter are both lactose-intolerant."
D. "My husband and our daughter are both lactose-intolerant."
A father of a 5-year-old calls the nurse to report that his child, who has had an upper respiratory infection, is complaining of a headache, with a rectal temperature of 103°F/39.4°C. Which action has the highest priority? A. Determine if the child has any allergies to antibiotics. B. Instruct the parent to give the child tepid baths. C. Instruct the parent to increase the child's fluid intake. D. Tell the parent to take the child to the emergency department.
D. Tell the parent to take the child to the emergency department.
Ampicillin, 75 mg/kg, is prescribed for a 22-lb child. It is available in a solution that contains 250 mg/5 mL. How many milliliters should the nurse administer in one dose? _____
15
What actions will the nurse include in the care plan of a 12-year-old with juvenile idiopathic arthritis? (Select all that apply.) A. Encourage jogging as a form of exercise. B. Apply cold packs to the affected joints. C. Position the affected joints in a neutral position. D. Warm shower or bath in the morning upon rising. E. Limit NSAIDs to avoid dependence.
B. Apply cold packs to the affected joints. C. Position the affected joints in a neutral position. D. Warm shower or bath in the morning upon rising.
A child admitted to the emergency department is lethargic and has a fruity aroma to the breath, blurred vision, and a headache. What question will the nurse ask the parents first? A. "Has your child ever been treated for diabetes before this?" B. "Has your child been playing outside in the heat all day?" C. "Are any of your other children displaying these symptoms?" D. "Has your child been exposed to other sick children?"
A. "Has your child ever been treated for diabetes before this?"
Following the administration of immunizations to a 6-month-old infant, the nurse provides the family with home care instructions. Which statement by the mother indicates that further teaching is needed? A. "I will give my baby a baby aspirin every 4 hours as needed for fever." B. "I will call the clinic if my baby's cry becomes high-pitched or unusual." C. "I know I can expect my baby to be irritable over the next 2 days." D. "I will exercise my baby's legs regularly to decrease the soreness."
A. "I will give my baby a baby aspirin every 4 hours as needed for fever."
Which statement by the older school-age child indicates to the nurse the teaching was effective for seizure precautions? (Select all that apply.) A. "I will wear my helmet with my wrist and shin guards when I ride my bike." B. "I can never ride my skateboard again or watch my friends skateboard." C. "I will wear my medical ID bracelet only when I am outside of the house." D. "I will always swim with a friend or family member; I will never swim alone." E. "I will make sure I take my seizure medication when I brush my teeth at night."
A. "I will wear my helmet with my wrist and shin guards when I ride my bike." D. "I will always swim with a friend or family member; I will never swim alone." E. "I will make sure I take my seizure medication when I brush my teeth at night."
The clinic nurse is reviewing information with parents whose child was recently diagnosed with autism spectrum disorder. Which statements by the parents indicate to the nurse that they understand the teaching? (Select all that apply.) A. "Repetitive movements are common." B. "Loves to interact with same age children." C. "Non-verbal communication is limited." D. "Frequently reaches out to be comforted." E. "Maintain a daily routine whenever possible."
A. "Repetitive movements are common." C. "Non-verbal communication is limited." E. "Maintain a daily routine whenever possible."
The nurse is assessing a male adolescent client's knowledge of contraception. The teen states, "I have all the info I need." What is the best response by the nurse? A. "Tell me what you know about birth control." B. "Do you know how to apply a condom?" C. "Teen pregnancy should not be taken lightly." D. "You need to visit with your guidance counselor."
A. "Tell me what you know about birth control."
A mother of a 4-year-old calls the clinic and reports that her child has non-regular, hard and dry stools. She reports a diet high in whole milk, processed meats, bananas, and macaroni and cheese. She states, "That's all I can get my child to eat right now." What is the nurse's best reply? A. "Try replacing the macaroni with a whole wheat macaroni." B. "Increasing the milk would be a good idea." C. "She what happens when you take away the banana." D. "Processed meats are not good for your child."
A. "Try replacing the macaroni with a whole wheat macaroni."
The nurse in the emergency department has recently admitted four children. Which child will the nurse bring to the attention of the health care provider first? A. A 2-year-old with vomiting and diarrhea for 48 hours B. A 4-year-old with a foreign body in the ear C. A 5-year-old with a temperature of 100°F/37.8°C D. A 7-year-old with green sputum and a respiratory rate of 20
A. A 2-year-old with vomiting and diarrhea for 48 hours
A 10-month-old is admitted for a tetralogy of Fallot repair. Which postoperative finding indicates that the repair is successful? (Select all that apply.) A. Absence of cyanosis when feeding B. Presence of a heart murmur C. Lips are pink when crying D. Heart rate 126 beats/min E. Respiratory rate 32 breaths/min
A. Absence of cyanosis when feeding C. Lips are pink when crying D. Heart rate 126 beats/min E. Respiratory rate 32 breaths/min
A 2-year-old child is placed in an oxygen tent. What clothes will the nurse recommend the parents bring from home for the child? A. An all-cotton sleeper B. A synthetic shirt and baggy shorts C. A polyester play outfit D. A lightly woven wool sweater
A. An all-cotton sleeper
The nurse is conducting an initial admission assessment of a 12-month-old child in celiac crisis. Which action is most important for the nurse to take first? A. Assess the child's mucous membranes and skin turgor. B. Contact food services about needed menu restrictions. C. Determine the child's food likes and dislikes. D. Ask the parents about the child's recent dietary intake.
A. Assess the child's mucous membranes and skin turgor.
The nurse is providing care to a child with a white blood cell count of 1.025 cell/mm³. What measures will the nurse take to decrease the risk for infection? (Select all that apply.) A. Assist with daily hygiene with an antimicrobial soap. B. Include fresh strawberries in the lunch menu. C. Replace the water in the pitcher every 4 hours. D. Encourage the addition of a green-leafy salad with supper. E. Offer a toothbrush and toothpaste after every meal and at bedtime.
A. Assist with daily hygiene with an antimicrobial soap. C. Replace the water in the pitcher every 4 hours. E. Offer a toothbrush and toothpaste after every meal and at bedtime.
The nurse is reviewing meal planning with a mother whose child is on furosemide. What high potassium selections will the nurse encourage the mother to include in the child's diet? (Select all that apply.) A. Bananas B. Mandarin oranges C. Strawberries D. Green peas E. Raisins F. Blueberries
A. Bananas B. Mandarin oranges E. Raisins
What information about skincare will the nurse include in the teaching plan for parent of a 3-month old with eczema? (Select all that apply.) A. Bath water should be tepid and use only a mild soap when needed. B. Apply a thick layer of corticosteroids to the affected areas 5 times a day. C. Apply a cool, wet washcloth to the affected area for 5 minutes at a time. D. Do not use fabric softener when washing any of your child's clothes. E. Keep your baby's nails short, and cover hands with cotton socks if needed.
A. Bath water should be tepid and use only a mild soap when needed. C. Apply a cool, wet washcloth to the affected area for 5 minutes at a time. D. Do not use fabric softener when washing any of your child's clothes. E. Keep your baby's nails short, and cover hands with cotton socks if needed.
A child is admitted to the hospital for confirmation of a diagnosis of acute lymphoblastic leukemia. During the initial nursing assessment, which symptoms will this child most likely exhibit? (Select all that apply.) A. Bone pain B. Tremors C. Nystagmus D. Abdominal distention E. Pallor
A. Bone pain E. Pallor
The nurse is teaching a group of new first-time parents about sudden infant death syndrome (SIDS). What will the nurse include in the teaching plan? (Select all that apply.) A. Boys are at higher risk for SIDS than girls. B. The high-risk period is after 9 months of age. C. Do not place the baby to sleep on its tummy. D. Napping on the sofa is acceptable. E. Sleeping with your newborn is encouraged
A. Boys are at higher risk for SIDS than girls. C. Do not place the baby to sleep on its tummy.
A nurse is preparing to end the shift and receives a laboratory report stating that a child with asthma has a theophylline level of 15 mcg/dL. Which action should the nurse take? A. Communicate the result to the oncoming nurse and document. B. Tell the oncoming nurse that the level is dangerously high. C. Ask the laboratory to redo the test because the result is faulty. D. Hold the next dose of theophylline based on this finding.
A. Communicate the result to the oncoming nurse and document.
The nurse is reviewing the discharge instructions of the parents of a 2-year-old who just underwent a myringotomy. What instructions will the nurse include in the parent's teaching? (Select all that apply.) A. Do not immerse the child's head in water when bathing. B. Administer the Tylenol as prescribed. C. Do not substitute aspirin for the prescribed Tylenol. D. Purchase earplugs and place them during bath time. E. Change the bandage on the ear three times a day.
A. Do not immerse the child's head in water when bathing. B. Administer the Tylenol as prescribed. C. Do not substitute aspirin for the prescribed Tylenol. D. Purchase earplugs and place them during bath time.
Which foods will the nurse include in the meal plan for iron deficiency anemia? (Select all that apply.) A. Dried fruits B. Nuts C. Cheese D. Spinach salad E. Cod F. Red meat
A. Dried fruits B. Nuts D. Spinach salad F. Red meat
Which food items to treat hypoglycemia will the nurse include in the teaching plan for the child with insulin-dependent diabetes? A. Half cup of fruit juice B. Four sugar cubes C. One teaspoon of honey D. Three hard candies E. One small box of raisins
A. Half cup of fruit juice B. Four sugar cubes C. One teaspoon of honey D. Three hard candies E. One small box of raisin
A burned child is brought to the emergency department, and the nurse uses a modified rule of nines to estimate the percentage of the body burned. When calculating the percentage of burn, which parts of the child's body are proportionally larger than an adult's body? (Select all that apply.) A. Head B. Arms C. Legs D. Back E. Neck F. Chest
A. Head E. Neck
The nurse is administering a fluid resuscitation for a child admitted with burns to the legs and abdomen. What assessments are essential to determine if the resuscitation is successful? (Select all that apply.) A. Heart rate B. Urine output C. Appetite D. Rapid capillary filling E. Range of motion F. Alertness
A. Heart rate B. Urine output D. Rapid capillary filling F. Alertness
A child is preparing for discharge from the hospital with the primary diagnosis of asthma. What will the nurse include in the child's discharge plan? (Select all that apply.). A. Home assessment for environmental allergens B. Move the child into a single bedroom. C. Clean the corticosteroid dispenser once a month. D. Teach the parents about peak expiratory flow rates. E. Increase the amount of daily carbohydrates and proteins.
A. Home assessment for environmental allergens B. Move the child into a single bedroom. D. Teach the parents about peak expiratory flow rates.
The health care provider has prescribed a gluten-free diet for the child suspected of having Celiac disease. Which items will the nurse need to correct when the parents are reviewing the child's dietary recommendations? (Select all that apply.) A. Ice cream purchased from the grocery store B. Hamburger with lettuce and onions C. Fried rice with chicken and peas D. Mixed green salad with strawberries E. Spaghetti with homemade sauce
A. Ice cream purchased from the grocery store
The nurse is reviewing a list of allowable immunizations which was developed by the parents of a child with leukemia. Which immunizations will the nurse to correct from the parents' lists? (Select all that apply.) A. Measles B. Mumps C. Rubella D. Varicella E. Hepatitis B
A. Measles B. Mumps C. Rubella D. Varicella
Which actions should the nurse include in the teaching plan for the mother of a 6-year-old who is experiencing encopresis secondary to a fecal impaction? (Select all that apply.) A. Provide a low-fiber diet. B. Administer mineral oil daily. C. Decrease the daily fluids. D. Eliminate dairy products. E. Initiate consistent toileting routine.
B. Administer mineral oil daily. D. Eliminate dairy products. E. Initiate consistent toileting routine.
The clinic nurse is reviewing the newly received lab reports. The report from an 8-year-old indicates chlamydial conjunctivitis. What is the nurse's next action? A. Have the parents bring the child in for further examination. B. Alert the proper authorities of possible sexual abuse. C. Ask the health care provider to call in a prescription for the child. D. Assess the child's chart to determine if immunizations are up-to-date.
B. Alert the proper authorities of possible sexual abuse.
Which nursing interventions are therapeutic when caring for a hospitalized toddler? (Select all that apply.) A. Require parents to leave the room when performing invasive procedures. B. Allow the toddler to choose a colored Band-Aid after an injection. C. Give brief but simple explanations to the child before procedures. D. Insert a urinary catheter if bedwetting occurs during hospitalization. E. Do not allow any toys to be brought in from the child's home.
B. Allow the toddler to choose a colored Band-Aid after an injection. C. Give brief but simple explanations to the child before procedures.
During routine screening at a school clinic, an otoscope examination of a child's ear reveals a tympanic membrane that is pearly gray, slightly bulging, and not movable. Based on these findings, what action should the nurse take? A. No action is required because this is an expected finding for a school-aged child. B. Ask if the child has had a cold, runny nose, or any ear pain lately. C. Send a note home advising parents to have the child evaluated by a health care provider. D. Call the parents and have them take the child home from school for the rest of the day.
B. Ask if the child has had a cold, runny nose, or any ear pain lately.
After a 3-day hospitalization for croup, secondary to mycoplasma pneumonia, the nurse is working with the parents to discharge the child home. The parents state to the nurse, "we do not have the money to purchase the right kind of vaporizer." What is the nurse's best action? A. Give the parents $30 cash from a personal fund. B. Ask, "Do you have a freezer with your refrigerator?" C. Ask, "Do you have any relatives nearby that could purchase the vaporizer." D. Give the parents an old hospital vaporizer with warm, moist heat.
B. Ask, "Do you have a freezer with your refrigerator?"
The nurse is preparing a teaching plan for the mother of a child who has been diagnosed with celiac disease. Choosing which lunch will be within the therapeutic management of a child with celiac disease? A. Turkey salad, milk, and oatmeal cookies B. Baked chicken, coleslaw, soda, and frozen fruit dessert C. Tuna salad sandwich on whole wheat bread, milk, and ice cream D. Turkey sandwich on rye bread, orange juice, and fresh fruit
B. Baked chicken, coleslaw, soda, and frozen fruit dessert
An infant post shunt replacement for hydrocephalus suddenly awakens with a high pitched, shrill cry and cannot be comforted. What is the next nursing action? A. Bring the parents to the infant's bedside. B. Contact the health care provider. C. Monitor the infant's intake and output. D. Pat the infant gently on its back.
B. Contact the health care provider.
What assessment findings will the nurse expect to see in a 9-month-old with cerebral palsy? (Select all that apply.) A. Absence of the Moro reflex B. Presence of the Babinski reflex C. Presence of the tonic neck reflex D. Irritability and excessive crying E. Rigidity of the arms and legs F. Coordinated suck-swallow when feeding
B. Presence of the Babinski reflex C. Presence of the tonic neck reflex D. Irritability and excessive crying E. Rigidity of the arms and legs
The nurse is receiving report from the emergency department on an 8-month-old child scheduled for a craniotomy. Which assessments will the nurse include in the child's care plan to evaluate for increased intracranial pressure? (Select all that apply.) A. Sunken fontanel B. Prominent sclera over the iris C. Listlessness D. Poor suck-swallow when feeding E. Increased head circumference
B. Prominent sclera over the iris D. Poor suck-swallow when feeding E. Increased head circumference
The nurse is preparing to administer eardrops to a 2-year-old. What is the proper procedure for administering this medication? A. Pull the pinna up and back. B. Pull the pinna down and back. C. Pull the pinna up and forward. D. Pull the pinna down and forward.
B. Pull the pinna down and back.
An 18-month-old child returns to the unit following a cardiac catheterization with a cannulated femoral artery site. Which action will the nurse include when teaching the parents about immediate post-procedure care? A. Teach the parents how to ambulate the child in the room safely. B. Show the parents how to hold the child with the extremity extended. C. Restrain the child's lower extremities for a minimum of 4 hours. D. Place the child in a prone position to apply pressure to the site.
B. Show the parents how to hold the child with the extremity extended.
The nurse is preparing a health teaching program for parents of toddlers and preschoolers, and plans to include information about the prevention of accidental poisonings. It is most important for the nurse to include which instruction? A. Tell children that they should not taste anything but food. B. Store all toxic agents and medicines in locked cabinets. C. Provide special play areas in the house and restrict play in other areas. D. Punish children if they open cabinets that contain household chemicals.
B. Store all toxic agents and medicines in locked cabinets.
A nine-year-old is admitted to the emergency department with blunt force trauma to the skull from a bike accident. Which assessment finding is most reassuring to the nurse? A. Vital signs are heart rate of 84 and respiratory rate of 16. B. Presence of a headache and visual changes C. Pupil size is unequal and sluggish. D. Alert and oriented to person, place, time, and situation
D. Alert and oriented to person, place, time, and situation
An infant is admitted with the medical diagnosis of coarctation of the aorta. What findings from the child's initial assessment support this medical diagnosis? (Select all that apply.) A. Dilated scalp veins B. Separated cranial suture lines C. Bulging anterior fontanels D. Bounding pulses in the arms E. Cool lower extremities
D. Bounding pulses in the arms E. Cool lower extremities
A mother calls the clinic because her 6-year-old son, who has been taking prescribed antibiotics for 7 of the previous 10 days, continues to have a cough that she reports is worsening. Further questioning by the nurse reveals that the cough is nonproductive. What is the nurse's best instruction to the mother? A. Watch the boy a few more days and see if the cough begins to produce sputum. B. The full 10-day course of antibiotics must be completed before effectiveness can be evaluated. C. Give the child plenty of fluids and an over-the-counter cough suppressant. D. Bring the child to the clinic today for an examination related to the cough.
D. Bring the child to the clinic today for an examination related to the cough.
The nurse is planning postoperative care for a child who has had a cleft lip repair. What is the most important reason to minimize this child's crying during the recovery period? A. Tear formation increases salivation. B. This behavior increases respirations. C. Excessive hysteria can lead to vomiting. D. Crying stresses the suture line.
D. Crying stresses the suture line.
The nurse is examining a male child experiencing an exacerbation of juvenile rheumatoid arthritis (JRA) and notes that mobility is greatly reduced. What is the most likely cause of the child's impaired mobility? A. Pathologic fractures B. Poor alignment of joints C. Dyspnea on exertion D. Joint inflammation
D. Joint inflammation
A 9-year-old child is recovering from a tonsillectomy. The nurse notes that the child is swallowing frequently. What is the nurse's next action? A. Call the health care provider. B. Suction the child's oral cavity. C. Instruct the child to cough. D. Place in a side-lying position.
D. Place in a side-lying position.
The nurse is helping a family prepare to send their 7-year-old child to school for the first time. The child is wheel-chair bound, and has a permanent tracheostomy. What information must the nurse include in the teaching plan for the child? A. Cover the tracheostomy site with clothing so that other children will not notice. B. Apply suction for 30 seconds when inserting a catheter into the stoma. C. Discourage the child from coughing deeply to remove mucous secretions. D. Place suctioning supplies on the back of the wheelchair when transporting.
D. Place suctioning supplies on the back of the wheelchair when transporting.
A child is recovering from a splenectomy secondary to a diagnosis of β-Thalassemia major. What is the most important instruction the nurse must include in the child's discharge plan? A. Parental genetic counseling B. Include the pneumococcal vaccine. C. Weekly hemoglobin levels D. Report signs of infection.
D. Report signs of infection.
The nurse is reviewing the laboratory results for a child admitted to rule out cystic fibrosis. Which test result should the nurse bring to the immediate attention of the health care provider? A. Serum sodium level of 135 mEq/L B. Serum sodium level of 145 mEq/L C. Sweat chloride concentration of 20 mEq/L D. Sweat chloride concentration of 80 mEq/L
D. Sweat chloride concentration of 80 mEq/L
