NCLEX Review Chapter 28-38
The nurse has provided instructions to the mother of an infant with viral pneumonia. Which statement by the mother would indicate the need for further teaching? 1. I understand I will need to have my baby on antibiotics for this pneumonia 2. I will need to give a cough suppressant before meals if his cough gets too bad 3. i will be careful and allow my baby to sleep so be can conserve energy and fight this infection 4. I understand that my baby has viral pneumonia and I need to monitor his temperature because of the risk for febrile seizure
1. I understand I will need to have my baby on antibiotics for this pneumonia
The nurse was caring for an infant who had come to the nursing unit for observation and treatment of tetralogy of Fallot. The child suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. The nurse would perform which action first? 1. Assist to administer morphine sulfate 2. Place the child in a knee-chests position 3. Administer 100% oxygen by face mask 4. Prepare to administer IV fluids
2. Place the child in a knee-chests position
The nurse is reinforcing home-care instructions to the parents of a 3 yr old child with scabies. Which statement by a parent indicates the need for further teaching? 1. I understand that I need to leave the scabicide on for 4 hrs before washing it off 2. I will need to seal up all my child's non-washable toys in a plastic bag for at least 4 days 3. I realize that everyone who has come in contact with my child will need to be treated for scabies 4. I know I need to wash all the clothing and bedding in hot water with detergent and dry in a hot dryer
1. I understand that I need to leave the scabicide on for 4 hrs before washing it off
The nurse assists to create a nursing care plan for the child with an arm cast and would include which interventions in the plan? Select all the apply 1. Instruct parents to keep the cast clean and dry 2. Monitor the extremity for circulatory impairment 3. Instruct the child not to stick objects down the cast 4. Ensure that rough cast material are cut off to keep the edges smooth 5. Notify the RN immediately if circulatory impairment occurs
1. Instruct parents to keep the cast clean and dry 2. Monitor the extremity for circulatory impairment 3. Instruct the child not to stick objects down the cast 5. Notify the RN immediately if circulatory impairment occurs
The nurse has reinforced homecare instructions to the parent of a child who is being discharged after cardiac surgery. Which statement by the parent indicates the need for further teaching? 1. A balance of rest and exercise is important 2. I can apply lotion or powder to the incision if it is itchy 3. Activities during which the child could fall need to be avoided for 2 -4 weeks 4. Large crowds of people need to be avoided for at least 2 weeks after this surgery
2. I can apply lotion or powder to the incision if it is itchy
The nurse reinforces home-care instructions to the parents of a child with hepatitis regarding the care of the child and the prevention of the transmission of the virus. Which statement by a parent indicates a need for further teaching? 1. Frequent hand washing is important 2. I need to provide a well-balanced high fat diet to my child 3. I need to clean contaminated household surfaces with bleach 4. Diapers should never be changed near any surfaces that are used to prepare food
2. I need to provide a well-balanced high fat diet to my child
The nurse reinforces instructions to the mother of a child with croup about the measures to take if an acute spasmodic episode occurs. Which statement by the mother indicates the need for further teaching? 1. I will take my child out into the humid night air 2. I will place a steam vaporizer in my child's bedroom 3. I will place a cool-mist humidifier in my child's bedroom 4. I will place my child in a closed bathroom and allow my child to inhale steam from the running water
2. I will place a steam vaporizer in my child's bedroom
A child is brought to the ER and the mother reports that the child accidentally swallowed paint thinner after mistaking it for water. The nurse must perform which action first? 1. Begin resuscitation 2. Terminate exposure to the poison 3. Take measures to prevent absorption of the poison 4. Check the airway, breathing, and circulation status of the child
4. Check the airway, breathing, and circulation status of the child
An infant returns to the nursing unit after the surgical repair of a cleft lip located on the right side of the lip. Which is the best position to place this infant at this time? 1. A flat position 2. A prone position 3. On his or her left side 4. On his or her right side
3. On his or her left side
The child with cryptorchidism is being discharged after orchiopexy, which was performed on an outpatient basis. The nurse would reinforce instructions to the parents about which priority care measure? 1. Measuring intake and output 2. Administering anticholinergics 3. Preventing infection at the surgical site 4. Applying cold, wet compresses to the surgical site
3. Preventing infection at the surgical site
The nurse monitors a 5 yr old child admitted to the hospital for a neuroblastoma for signs/symptoms related to the location of the tumor in the adrenal gland. Which description would the nurse expect to be documented in the child's record specific to this tumor? Select all that apply 1. Respiratory impairment 2. Anorexia and weight loss 3. Pallor, weakness, irritability 4. Supraorbital ecchymosis and periorbital edema 5. Firm, nontender, irregular mass in the abdomen 6. Urinary frequency or retention from compression on the bladder
5. Firm, nontender, irregular mass in the abdomen 6. Urinary frequency or retention from compression on the bladder
The nurse is monitoring for signs of dehydration in a 1 yr old child who has been hospitalized for diarrhea and prepares to take the child's temperature. Which method of temperature measurement needs to be avoided? 1. Rectal 2. Axillary 3. Electronic 4. Tympanic
1. Rectal
The nurse reinforces instructions to the mother about dietary measures for a 5 yr old child with lactose intolerance. The nurse would tell the mother that which supplement will be required as a result of the need to avoid lactose in the diet? 1. Fats and vitamin A 2. Zinc and vitamin C 3. Calcium and vitamin D 4. Thiamine and vitamin B
3. Calcium and vitamin D
A child has fluid volume deficit. The nurse collects data and determines that the child is improving and the deficit is resolving if which finding it noted? 1. The child has no tears 2. Urine specific gravity is 1.030 3. Capillary refill is less than 2 seconds 4. Urine output is less than 1 mL/kg/h
3. Capillary refill is less than 2 seconds
The nurse observes a mother giving oral iron supplement to her 6 yr old with iron deficiency anemia. Which action by the mother indicates the need for further teaching? 1. The mother administered the iron with milk 2. The mother administered the iron with water 3. The mother administered the iron with apple juice 4. The mother administered the iron with orange juice
1. The mother administered the iron with milk
The pediatrician has prescribed an antibiotic for a child. The average adult dose is 500 mg. The child has a body surface area (BSA) of 0.63 m2 What is the dose for the child?
182 mg
The nurse is instructing the mother of a child with cystic fibrosis (CF) about the appropriate dietary measures. Which meal best illustrates the most appropriate diet for a client with CF? 1. Veggie salad and a caramel apple 2. Strawberry jelly sandwich and pretzels 3. Plate of nachos and a cheese and a cupcake 4. Chicken tenders and a baked potato with butter
2. 4. Chicken tenders and a baked potato with butter
Isoniazid is prescribed for a 2-year-old child with a positive tuberculin skin test. The mother of the child asks the nurse how long the child will need to take the medication. Which time frame is the appropriate response to the mother? 1. 4 months 2. 9 months 3. 12 months 4. 18 months
2. 9 months
The nurse is reviewing the postoperative prescriptions for an infant with hydrocephalus, who came back from surgery with a ventriculoperitoneal shunt. Which of the surgeon's prescriptions does the nurse question? 1. Position the infant on the nonoperative side 2. Keep the head of the bed elevated 45 degrees 3. Monitor for signs of infection and check dressings for drainage 4. Observe for irritability, a high shrill cry, lethargy and poor feeding
2. Keep the head of the bed elevated 45 degrees
The nurse is monitoring for bleeding in a child after surgery to remove a brain tumor. The nurse checks the head dressing for the presence of blood and notes a colorless drainage on the back of the dressing. Which nursing action is appropriate? 1. Reinforce the dressing 2. Notify the RN 3. Document the findings and continue to monitor 4. Circle the area of drainage and continue to monitor
2. Notify the RN
The nursing instructor asks a nursing student about phenylketonuria (PKU). Which statement made by the student indicates a need for further teaching? 1. PKU is an autosomal-recessive disorder 2. PKU primarily affects the gastrointestinal system 3. Treatment of PKU includes the dietary restriction of phenylalanine 4. All 50 states require routine screening of all newborns for PKU
2. PKU primarily affects the gastrointestinal system
Morphine sulfate, 2.5 mg, is prescribed for a child. The safe pediatric dose is 0.05 mg/kg/dose to 0.1 mg/kg/dose. The child weighs 50 kg. Which statement accurately describes the prescribed dosage for this child? 1. The dose is too low 2. The dose is too high 3. The dose is within the safe dosage range 4. There is not enough information to determine the safe dosage range
3. The dose is within the safe dosage range
The nurse is working in the ED and caring for a child who has been diagnosis with epiglottitis. Which is an indication that the child may be experiencing airway obstruction? 1. Retractions and coughing 2. Nasel flaring and bradycardia 3. Tripod positioning and dyspnea 4. A low-grade fever and complaints of a sore throat
3. Tripod positioning and dyspnea
The mother of a child with juvenile idiopathic arthritis calls the nurse because the child is experiencing a painful exacerbation of the disease. The mother asks the nurse if the child should reform ROM exercise at this time. The nurse would make which response to the mother? 1. Avoid all exercise during painful periods 2. The ROM exercise must be performed every day 3. have the child perform simple isometric exercises during the time 4. Administer additional pain medication before performing the ROM exercises
3. have the child perform simple isometric exercises during the time
Sulfisoxazole, 1 g orally four times daily, is prescribed for an adolescent with a urinary tract infection. The medication label reads "250-mg tablets." The nurse has determined that the prescribed dose is safe. How many tablets per dose should the nurse administer to the adolescent?
4 tablets
A primary health care provider has prescribed oxygen as needed for a 10 month old infant with HF. In which situation would the nurse administer the oxygen to the child? 1. When the child is sleeping 2. When changing the child's diapers 3. When the mother is holding the child 4. When drawing blood for electrolyte levels
4. When drawing blood for electrolyte levels
The nurse is assisting in performing pediculosis capitis (head lice) checks. Which finding indicates that a child has a "positive" head check? 1. Maculopapular lesions behind the ears 2. Lesions in the scalp that extend to the hairline or neck 3. White flaky particles throughout the entire scalp region 4. White sacs attached to the hair shafts in the occipital area
4. White sacs attached to the hair shafts in the occipital area
The PHCP has prescribed phenobarbital sodium 25 mg orally twice daily for a child with febrile seizures. The label reads phenobarbital sodium 20 mg/5 mL. The nurse has determined that the dose prescribed is a safe dose for the child. How many milliliters per dose would the nurse administer to the child?
6.25 mL
The PHCP's prescription reads acetaminophen 240 mg orally every 6 hrs as needed for relief, for a 5 yr old child. The medication label reads "acetaminophen 160 mg per 5 mL. The nurse has determined that the dose prescribed is safe. How many mL per dose would the nurse administer to the child?
7.5 mL
A child has a basilar skull fracture. Which PHCP's prescription would the nurse question? 1. Restrict fluid intake 2. Insert an indwelling urinary catheter 3. Keep an IV line patent 4. Suction via the nasotracheal route as needed
4. Suction via the nasotracheal route as needed
A child is diagnosed with scarlet fever. The nurse collects data regarding the child. Which is characteristic of scarlet fever? 1. Pastia's sign 2. Abdominal pain and flaccid paralysis 3. Dense pseudoformation membrane in the throat 4. Foul-smelling and mucopurulent nasal drainage
1. Pastia's sign
A child with rubeola (measles) is being admitted to the hospital. When preparing for the admission of the child, which precautions would be implemented? Select all that apply 1. Enteric 2. Contact 3. Airborne 4. Protective 5. Neutropenic
2. Contact 3. Airborne
An 18 month old child is being discharged after surgical repair of hypospadias. Which postoperative nursing care measure would the nurse stress to the parents as they prepare to take this child home? 1. Leave diapers off to allow the site to heal 2. Avoid tub baths until stent has been removed 3. Encourage toilet training to ensure that the flow of urine is normal 4. Restrict the fluid intake to reduce urinary output for the first few days
2. Avoid tub baths until stent has been removed
The nurse collects a urine specimen preoperatively from a child with epispadias who is scheduled for surgical repair. The nurse reviews the child's record for the laboratory results of the urine test and would most likely except to note which finding? 1. Hematuria 2. Bacteriuria 3. Glucosuria 4. Proteinuria
2. Bacteriuria
A child with a diagnosis of a hernia has been scheduled for a surgical repair in 2 weeks. The nurse reinforces instructions to the parents about the signs of possible incarcerated hernia. The nurse tells the parents that which manifestation requires PHCP notification by the parents? 1. Pain 2. Diarrhea 3. Constipation 4. Increased flatus
1. Pain
A child is admitted to the hospital with a probable diagnosis of nephrotic syndrome. Which findings would the nurse expect to observe? Select all that apply 1. Ascites 2. Anorexia 3. Weight loss 4. Proteinuria 5. Decreased serum lipids 6. Periorbital and facial edema
1. Ascites 2. Anorexia 4. Proteinuria 6. Periorbital and facial edema
The nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by the respiratory syncytial virus (RSV). Which interventions would be included in the plan of care? Select all that apply 1. Place infant in a private room 2. Place infant in a room near the nurses' station 3. Ensure that the infant's head is in a flexed position 4. Wear a mask at all times when in contact with the infant 5. Place the child in a tent that delivers warm, humidified air 6. Position the infant side-lying with the head lower than the chest
1. Place infant in a private room 2. Place infant in a room near the nurses' station 4. Wear a mask at all times when in contact with the infant
The nurse reinforces home-care instructions to the parents of a child with celiac disease. Which food item would the nurse advise the parents to include in the child's diet? 1. Rice 2. Oatmeal 3. Rye toast 4. Wheat bread
1. Rice
The nurse caring for a child who sustained a burn injury plans care based on which pediatric considerations associated with this injury? Select all that apply 1. Scarring is less severe in a child than in an adult 2. A delay in growth may occur after a burn injury 3. An immature immune system presents an increased risk of infection for infants and young children 4. Fluid resuscitation is unnecessary unless the burned area is more than 25% of the total body surface area 5. The lower proportion of body fluid to body mass in a child increase the risk of cardiovascular problems 6. Infants and young children are at increased risk for protein and calorie deficiency because they have smaller muscle mass less body fat than adults
2. A delay in growth may occur after a burn injury 3. An immature immune system presents an increased risk of infection for infants and young children 6. Infants and young children are at increased risk for protein and calorie deficiency because they have smaller muscle mass less body fat than adults
A nurse reviews the record of a child who was just seen by a health care provider (HCP). The HCP has documented a diagnosis of suspected aortic stenosis. Which specific sign/symptom of aortic stenosis would the nurse anticipate? 1. Pallor 2. Hyperactivity 3. Activity intolerance 4. Gastrointestinal disturbances
3. Activity intolerance
A 6 month old infant receives a DTaP immunization at the well-baby clinic. The parent returns home and calls the clinic to report that the infant has developed swelling and redness at the site of injection. Which instruction by the nurse is appropriate? 1. Monitor the infant for a fever 2. Bring the infant back to the clinic 3. Apply an ice pack to the injection site 4. Leave the inject site alone, because this always occurs
3. Apply an ice pack to the injection site
A nurse assists with admitting a child with a diagnosis of acute-stage Kawasaki disease. When obtaining the child's medical history, which clinical manifestation is likely to be reported? 1. Cracked lips 2. A normal appearance 3. Conjunctival hyperemia 4. Desquamation of the skin
3. Conjunctival hyperemia
The nurse has just administered ibuprofen to a child with a temperature of 102F. The nurse would also take which action? 1. Withold oral fluids for 8 hrs 2. Sponge the child with cold water 3. Plan to administer salicylate in 4 hrs 4. Remove excess clothing and blankets from the child
4. Remove excess clothing and blankets from the child
The mother of a toddler with mumps asks the nurse what she needs to watch for in her child with this disease. The nurse bases the response on the understanding that mumps is which type of communicable disease? 1. Skin rash caused by a virus 2. Skin rash caused by a bacteria 3. Respiratory disease caused by virus involving the lymph nodes 4. Respiratory disease caused by a virus involving the parotid gland
4. Respiratory disease caused by a virus involving the parotid gland
The nurse is assisting a PHCP during an examination of an infant with hip dysplasia. The PHCP performs the Ortolani maneuver. Which data would the nurse expect to note during the examination? 1. Full range of ROM of the legs 2. Marked asymmetry on the affected side 3. The unstable femoral head pops out of the acetabulum 4. The dislocated femoral head pops back into the acetabulum
4. The dislocated femoral head pops back into the acetabulum
A mother brings her 3 week old infant to a clinic for a phenylketonuria (PKU) rescreening blood test. The test indicates a serum phenylalanine level of 0 mg/dL. The nurse reviews this result and makes which interpretation? 1. It is negative 2. It is a concern 3. It is inconclusive 4. It requires rescreening at age 6 weeks
1. It is negative
A child is diagnosed with chicken pox. The nurse collects data regarding the child. Which finding is characteristic of chicken pox? 1. Macular rash on the trunk and scalp 2. Pseudomembrane formation in the throat 3. Maculopapular or petechial rash on the extremities 4. Small, red spots with a bluish-white center and red base
1. Macular rash on the trunk and scalp
The nurse reinforces instructions to the parents of a child with leukemia regarding measures related to monitoring for infection. Which statement by the parents indicates the need for further teaching? 1. I need to use proper hand-washing techniques 2. I need to take my child's rectal temperature daily 3. I need to inspect my child's skin daily for redness 4. I need to inspect my child's mouth daily for lesions
2. I need to take my child's rectal temperature daily
The nurse reviews the record of an infant who is seen in the clinic. The nurse notes that a diagnosis of esophageal atresia with tracheoesophageal fistula (TEF) is suspected. The nurse expects to note which most likely manifestation of this condition in the medical record? 1. Incessant crying 2. Coughing at nighttime 3. Choking with feedings 4. Severe projectile vomiting
3. Choking with feedings
Which laboratory result would verify the diagnosis of bacterial meningitis? 1. Clear cerebrospinal fluid with high protein and low glucose levels 2. Cloudy cerebrospinal fluid with low protein and low glucose levels 3. Cloudy cerebrospinal fluid with high protein and low glucose levels 4. Decreased pressure and cloudy cerebrospinal fluid with a high protein level
3. Cloudy cerebrospinal fluid with high protein and low glucose levels
The nurse caring for a child with aplastic anemia is reviewing the laboratory results and notes a WBC count of 6000 mm3 and a platelet count of 20,000 mm3. Which nursing intervention would be incorporated into the plan of care? 1. Encourage naps 2. Encourage a diet high in iron 3. Encourage quiet play activities 4. Maintain strict isolation precautions
3. Encourage quiet play activities
A adolescent client with type 1 diabetes mellitus is admitted to the ED for treatment of diabetic ketoacidosis. Which assessment findings would the nurse expect to note? 1. Sweating and tremors 2. Hunger and hypertension 3. Cold, clammy skin and irritability 4. Fruity breath and decreasing level of consciousness
4. Fruity breath and decreasing level of consciousness
The nurse is assigned to care for a child after a myringotomy with the insertion of tympanostomy tubes. The nurse notes a small amount of reddish drainage from the child's ear after the surgery. On the basis of this finding which action would the nurse take? 1. Document the findings 2. Notify the RN immediately 3. Change the ear drainage for the presence of cerebrospinal fluid
1. Document the findings
A school-age child with type 1 diabetes mellitus has soccer practice three afternoons a week. The nurse reinforces instructions regarding how to prevent hypoglycemia during practice. Which would the nurse tell the child? 1. Drink a half of cup of orange juice before soccer practice 2. Eat twice the amount that is normally eaten at lunchtime 3. Take half of the amount of prescribed insulin on practice day 4. Take the prescribed insulin at noontime rather than in the morning
1. Drink a half of cup of orange juice before soccer practice
The nurse is reviewing instructions to a parent of a 6 yr old on how to prevent influenza. Which statement by the parent indicates a need for further teaching? 1. I will get a flu shot and I will have my child get a flu shot too 2. I will avoid having my child come into contact with sick children 3. I will have my child wash her hands frequently during the flu season 4. I will not let my child play other children who have the flue unless they are taking acetaminophen
4. I will not let my child play other children who have the flue unless they are taking acetaminophen
The nurse provides homecare instructions to the parents of a child with HF regarding the procedure for the administration of digoxin. Which statement by a parent indicates the need for further teaching? 1. I will not mix the medication with food 2. If more than one dose is missed, I will call the doctor 3. I will take my child's pulse before administering the medication 4. If my child vomits after medication administration, I will repeat the dose
4. If my child vomits after medication administration, I will repeat the dose
A 4 yr old child sustains a fall at home injuring the right arm and is brought to the ED by the mother. The nurse would perform which emergency actions in the care of the child? Select all that apply 1. Elevate the right arm 2. Apply warm packs to the right arm 3. Check the neurovascular status of the right extremity 4. Check the ROM of the right arm and shoulder 5. Determine the level of pain using a pediatric pain assessment tool
1. Elevate the right arm 3. Check the neurovascular status of the right extremity 5. Determine the level of pain using a pediatric pain assessment tool
The nurse is assigned to care for a child who is scheduled for an appendectomy. Which prescriptions does the nurse anticipate to be prescribed? Select all that apply 1. Administer a Fleet enema 2. Initiate an IV line 3. Maintain nothing-by-mouth status 4. Administer IV antibiotics 5. Administer preoperative medications 6. Place a heating pad on the abdomen to decrease pain
2. Initiate an IV line 3. Maintain nothing-by-mouth status 4. Administer IV antibiotics 5. Administer preoperative medications
The nurse caring for an infant with congenital heart disease is monitoring the infant closely for signs of heart failure (HF). The nurse would observe for which early signs of HF? Select all that apply 1. Cough 2. Irritability 3. Scalp diaphoresis 4. Tachypnea, tachycardia 5. Slow and shallow breathing
2. Irritability 3. Scalp diaphoresis 4. Tachypnea, tachycardia
The nurse is reviewing the record of a child with a diagnosis of pyloric stenosis. Which data would the nurse expect to note as having been documented in the child's record? 1. Watery diarrhea 2. Projectile vomiting 3. Increased urine output 4. Vomiting large amounts of bile
2. Projectile vomiting
The nursing instructor asks a student to describe osteogenic sarcoma. Which statement by the student indicates the need to further research the disease? 1. The femur is the most common site of this sarcoma 2. The child does not experience pain at the primary tumor site 3. If a weight-bearing limb is affected, them limping is a clinical manifestation 4. The symptoms of the disease during the early stage are almost always attributed to normal growing pains
2. The child does not experience pain at the primary tumor site
The nursing instructor ask a nursing student about sudden infant death syndrome (SIDS). Which statement by the student indicates further teaching is needed? 1. Some of the interventions that are used to prevent SIDS include having infants sleep in the supine position 2. The incidence of SIDS has been found to be higher in breast-fed infants and infants that use a pacifier 3. Infants exposed to cigarette smoking during pregnancy and after birth are considered at risk for SIDS 4. SIDS refers to sudden infant death syndrome that can occur in healthy infants under 1 yr of age and no exact cause is known
2. The incidence of SIDS has been found to be higher in breast-fed infants and infants that use a pacifier
The nurse would implement which interventions for a child older than 2 yrs with type 1 diabetes mellitus who has a blood glucose level of 60 mg/dL? Select all that apply 1. Administer regular insulin 2. Encourage the child to ambulate 3. Give the child a teaspoon of honey 4. Provide electrolyte replacement therapy intravenously 5. Wait 30 minutes and confirm the blood glucose reading 6. Prepare to administer glucagon subcutaneously if unconsciousness occurs
3. Give the child a teaspoon of honey 6. Prepare to administer glucagon subcutaneously if unconsciousness occurs
The nurse is performing a neurovascular check on a hospitalized child who had a cast applied to the lower leg. The child complains of tingling in the toes distal to the fracture site. Which action would the nurse take? 1. Elevate the extremity 2. Document the findings 3. Notify the RN 4. Ambulate the child with crutches
3. Notify the RN
A child is diagnosed with infectious mononucleosis. The nurse reinforces homecare instructions to the parents about the care of the child. Which instruction would the nurse provide to the parents? 1. Maintain the child on bed rest for 2 weeks 2. Maintain respiratory precautions for 1 week 3. Notify the pediatrician if the child develops a fever 4. Notify the pediatrician if the child develops abdominal or left shoulder pain
4. Notify the pediatrician if the child develops abdominal or left shoulder pain
A 4 yr old child is hospitalized with a suspected diagnosis of Wilm's tumor. The nurse reviews the plan of care and would question with intervention that is written in the plan? 1. Palpate the abdomen for a mass 2. Check the urine for the presence of hematuria 3. monitor the blood pressure for the presence of hypertension 4. Monitor the temperature for the presence of a kidney infection
1. Palpate the abdomen for a mass
The nurse is planning care for a child with hemolytic-uremic syndrome (HUS). The child has been anuric and will be receiving peritoneal dialysis treatment. The nurse would plan to include which interventions in the care of the child? Select all that apply 1. Provide adequate 2. Restriction of fluids, as prescribed 3. Institute of fluids, as prescribed 4. Monitoring the arteriovenous (AV) fistula 5. Administer blood products to treat severe anemia 6. Anticipate the child will have central nervous system involvement
1. Provide adequate 2. Restriction of fluids, as prescribed 3. Institute of fluids, as prescribed 5. Administer blood products to treat severe anemia 6. Anticipate the child will have central nervous system involvement
After a tonsillectomy, the child begins to vomit bright red blood. which is the initial nursing action? 1. Turn the child to the side 2. Notify the RN 3. Administer the prescribed antiemetic 4. Maintain NPO status
1. Turn the child to the side
The mother of a 6 yr old child who has type 1 diabetes mellitus calls a clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the child's urine and it was positive for ketones. The nurse would instruct the mother to take which action? 1. Hold the next dose of insulin 2. Come to the clinic immediately 3. Encourage the child to drink liquids 4. Administer an additional dose of regular insulin
3. Encourage the child to drink liquids
The nurse provides information to the parent of a 2 week old infant who was diagnosed with clubfoot at the time of birth. Which statement by the parent indicates the need for further teaching regarding this disorder? 1. I understand treatment needs to be started as soon as possible 2. I realize my child will require follow-up care until fully grown 3. I need to bring my child back to the clinic in 2 months for a new cast 4. I need to come to the clinic every week with my child for casting
3. I need to bring my child back to the clinic in 2 months for a new cast
The nurse reinforces home care instructions to the parents of a child with a brace for scoliosis. Which statement by a parent indicates a need for further teaching? 1. I will inspect the skin under the brace for redness or breakdown 2. I will encourage my child to do their exercise to maintain strength 3. I understand that my child needs to wear this brace for 12 hrs a day 4. I understand that this brace is not a cure for scoliosis, it only slows the progression of the curvature
3. I understand that my child needs to wear this brace for 12 hrs a day
The nurse is assigned to care for a child who is in skeletal traction. The nurse needs to avoid which action when caring for the child? 1. Keeping the weights hanging freely 2. Ensuring that the ropes are in the pulleys 3. Placing the bed linens on the traction ropes 4. Ensuring that the weights are out of the child's reach
3. Placing the bed linens on the traction ropes
The nurse assists to prepare a teaching plan regarding the administration of eardrops for the parents of a 2 yr old child with otitis media. Which would be included in the plan? 1. Wear gloves when administering the eardrops 2. Pull the ear up and back before instilling the eardrops 3. Pull the earlobe down and back before instilling the eardrops 4. Hold the child in a sitting position when administering the eardrops
3. Pull the earlobe down and back before instilling the eardrops
The parents of a child recently diagnosed with cerebral palsy ask the nurse about the disorder. The nurse bases the response on the understanding that cerebral palsy is which type of condition? 1. An infectious disease of the central nervous system 2. an inflammation of the brain as a result of a viral illness 3. A congenital condition that results in moderate to severe retardation 4. A chronic disability characterized by impaired muscle movement and posture
4. A chronic disability characterized by impaired muscle movement and posture
The nurse is monitoring the daily weight of an infant with HF. Which finding alerts the nurse to suspect fluid accumulation and thus the need to notify the RN? 1. Bradypnea 2. Diaphoresis 3. Decreased blood pressure 4. A weight gain of 1 lb in 1 day
4. A weight gain of 1 lb in 1 day
A topical corticosteroid is prescribed by the pediatrician for a child with atopic dermatitis (eczema). Which instruction would the nurse give the parent about applying the cream? 1. Apply the cream over the entire body 2. Apply a thick layer of cream to affected areas only 3. Avoid cleansing the area before application of the cream 4. Apply a thin layer of cream and rub it into the area thoroughly
4. Apply a thin layer of cream and rub it into the area thoroughly
The nurse reinforces instruction to the parent of a child with meningococcal meningitis. Which statement by the parent indicates a need for further teaching? 1. I can give my child acetaminophen for fever 2. I will watch for any hearing loss that may occur 3. I know that I will need to watch for any rash that my child may develop 4. I will need to get my other children the pneumococcal vaccine, but not the baby yet he is only 3 months
4. I will need to get my other children the pneumococcal vaccine, but not the baby yet he is only 3 months
The nurse is providing discharge instruction to the parents of a 14 yr old child who is undergoing radiation for Hodgkin's disease. Which statement by a parent indicates the need for further teaching? 1. I need to watch for diarrhea, so my child does not get dehydrated 2. I think that once my child's hair starts to fall out that I can keep a hat on him 3. I understand that the radiation will cause nausea and vomiting and I need to keep my child hydrated 4. I will need to keep my child's skin from flaking, so we will be allowing showers every 2-3 days
4. I will need to keep my child's skin from flaking, so we will be allowing showers every 2-3 days
A child with type 1 diabetes mellitus is brought to the ED by the mother, who states that the child has been complaining of abdominal pain and has been lethargic. Diabetic ketoacidosis is diagnosed. Anticipating the plan of care, the nurse prepares to administer which type of IV infusion? 1. Potassium infusion 2. NPH insulin infusion 3. 5% dextrose infusion 4. Normal saline infusion
4. Normal saline infusion
A mother of a child with a diagnosis of intussusception calls the nurse into the hospital room because the child is screaming in pain. The nurse quickly assesses the child. Which manifestations of perforation and shock would the nurse report immediately? Select all that apply 1. Fever 2. Ribbon-like stools 3. Increased heart rate 4. Hypoactive bowel sounds 5. Profuse projectile vomiting 6. Change in the level of consciousness
1. Fever 3. Increased heart rate 6. Change in the level of consciousness
Which home care instruction would the nurse plan to reinforce to the mother of a child with AIDS? Select all that apply 1. Frequent hand washing is important 2. The child needs to avoid exposure to other illnesses 3. The child's immunization schedule will need revision 4. Kissing the child on the mouth will never transmit the virus 5. Clean up body fluid spills with bleach solution (10:1 ratio of water to bleach) 6. Fever malaise fatigue weight loss vomiting and diarrhea are excepted to occur and do not require special intervention
1. Frequent hand washing is important 2. The child needs to avoid exposure to other illnesses 5. Clean up body fluid spills with bleach solution (10:1 ratio of water to bleach)
The nurse is assigned to care for a child who is suspected of having glomerulonephritis. The nurse reviews the child's record and notes that which findings are associated with the glomerulonephritis? Select all the apply 1. Headache 2. Hypotension 3. Red-brown urine 4. Periorbital edema 5. Increased urine output 6. A low blood urea nitrogen (BUN) level
1. Headache 3. Red-brown urine 4. Periorbital edema
The mother of a child with Marfan syndrome asks the nurse what can be done to help her child. Which are the best responses by the nurse? Select all that apply 1. You will need to keep your child indoors and avoid sports 2. You will need to consider surgery in the future if recommended 3. You will need to make regular pediatric appointments for your child 4. You will need to make regular eye examination appointments for your child 5. You will need to be sure your child takes prescribed cardiac medication(s) to decrease stress on the aorta 6. You will need to let the dentist know so antibiotics can be prescribed before any procedure
2. You will need to consider surgery in the future if recommended 3. You will need to make regular pediatric appointments for your child 4. You will need to make regular eye examination appointments for your child 5. You will need to be sure your child takes prescribed cardiac medication(s) to decrease stress on the aorta 6. You will need to let the dentist know so antibiotics can be prescribed before any procedure
A parent with a 6 yr old child diagnosed with enuresis discusses with the nurse the measures that are being taken to help her child. Which statement by the parent indicates a need for further teaching? 1. I make sure that my child goes potty before going to bed 2. I will praise my child and think of a reward for him for staying dry 3. I take away privileges such as TV time when the bed is wet in the morning 4. I make sure that my child does not have anything to drink 2 hrs before bedtime
3. I take away privileges such as TV time when the bed is wet in the morning
The nurse instructs a mother of a child who has seizures regarding seizure precautions. Which statement by the mother indicates a need for further teaching? 1. I will make my child wear a medical identification alert bracelet 2. I know that my child will need to have a companion when swimming 3. I will need to give antiseizure medications when my child has a seizure 4. I will have my child wear a bike helmet when riding a bike or skateboarding
3. I will need to give antiseizure medications when my child has a seizure
The nurse is reinforcing discharge instructions to the parent of a 2 yr old child who has had an orchiopexy to correct cryptorchidism. Which statement by the parent indicates a need for further teaching? 1. I'll check his temperature 2. I'll give him medication so he'll be comfortable 3. I'll let him decide when to return to his play activities 4. I'll check his voiding to be sure there are no problems
3. I'll let him decide when to return to his play activities
The nurse is reviewing the postoperative surgeon's prescriptions for a 3 week old infant with Hirschsprung's disease admitted to the hospital for surgery. Which prescriptions documented in the child's record would the nurse question? Select all that apply 1. Measure abdominal girth daily 2. Monitor strict intake and output 3. Take temperature measurements rectally 4. Start clear liquid diet after 8 hrs postoperative 5. Maintain IV fluids until the child tolerates oral intake 6. Monitor the surgical site for redness, swelling, and drainage
3. Take temperature measurements rectally 4. Start clear liquid diet after 8 hrs postoperative
The nurse is told that a child with rheumatic fever (RF) will be arriving to the nursing unit for admission. Which question would the nurse ask the family to elicit information specific to the development of RF? 1. Has the child complained of back pain 2. Has the child complained of headaches 3. Has the child had any nausea or vomiting 4. Has the child had a sore throat or fever within the past 2 months
4. Has the child had a sore throat or fever within the past 2 months
The nurse has provided instruction to the mother of a child who has been diagnosed with bacterial conjunctivitis. Which statement by the mother would indicate the need for further teaching? 1. I need to wash my hands frequently 2. I need to clean the eye as prescribed 3. I need to give the eye drops as prescribed 4. I need to use hot compresses to relieve the eye irritation
4. I need to use hot compresses to relieve the eye irritation
The nurse reinforces home care instructions to the parents of a 3 yr old child who has been hospitalized with hemophilia. Which statement by a parent indicates the need for further teaching? 1. I will supervise my child closely 2. I will pad the corners of the furniture 3. I will remove household items that can easily fall over 4. I will avoid immunizations and dental hygiene treatments for my child
4. I will avoid immunizations and dental hygiene treatments for my child
The nurse revies measures to prevent tick bites with a parent of a child with Rocky Mountain spotted fever. Which statement by the parent indicates a need for further teaching? 1. I will have my child wear long sleeves and long pants to keep covered up 2. I will have my child stay on well-worn paths and not stray into tall grass 3. I will check my child for ticks after being exposed to a high-risk tick-infected area 4. I will have my child wear dark colored clothing so the tick will not be attracted to the colors
4. I will have my child wear dark colored clothing so the tick will not be attracted to the colors
The parent of a newborn have been told that their child was born with bladder exstrophy and the parents ask the nurse about this condition. Which response would the nurse give to the parents about bladder exstrophy? 1. It is hereditary disorder that occurs in every other generation 2. It is caused by the use of medications taken by the mother during pregnancy 3. It is a condition in which the urinary bladder is abnormally located in the pelvic cavity 4. It is an extrusion of the urinary bladder to the outside of the body through a defect in the lower abdominal wall
4. It is an extrusion of the urinary bladder to the outside of the body through a defect in the lower abdominal wall
The school nurse prepares a list of home care instruction for the parents of school children who have been diagnosed with pediculosis capitis (head lice). Which would be included in the list? Select all that apply 1. Siblings may also need treatment 2. Use antilice sprays on all bedding and furniture 3. Use a pediculicide shampoo and repeat treatment in 14 days 4. Grooming item such as combs and brushes should not be shared 5. Launder all the bedding and clothing in hot water and dry on high heat 6. Vacuum floors, play areas, and furniture to remove any hairs that may carry live nits
1. Siblings may also need treatment 4. Grooming item such as combs and brushes should not be shared 5. Launder all the bedding and clothing in hot water and dry on high heat 6. Vacuum floors, play areas, and furniture to remove any hairs that may carry live nits
The nurse is caring for an 18 month old child who has been vomiting. Which is the appropriate position to place the child during naps and sleep time? 1. A supine position 2. A side-lying position 3. Prone, with the head elevated 4. Prone, with the face tuned to the side
2. A side-lying position
The nurse provides homecare instructions to the parent of a child with attention deficit hyperactivity disorder regarding behavioral therapy interventions. Which statement by the parent indicates a need for further teaching? 1. I hear that the side effects of the medication that my child will be on can cause overeating 2. I know that consistent medication and regular follow-up visits are a part of the plan for my child 3. I know I need to maintain a consistent home environment because my child is easily distracted 4. I understand that I will need to learn some behavioral modification techniques to help my child's impulsivity
1. I hear that the side effects of the medication that my child will be on can cause overeating
The nurse is providing instructions to a parent of a child with patent ductus arteriosus (PDA). Which statement by the parent would indicate a need for further teaching? 1. I know that my child will outgrow this problem just give him time 2. I know that i need to be alert for signs of heart failure with this defect until it is repaired 3. The doctors tell me that my child has a heart murmur caused by the ductus not closing after birth 4. As I understand it, my child may have to have his defect closed, either during a catheterization or my surgery
1. I know that my child will outgrow this problem just give him time
The nurse is instructing a mother of a 1 yr old child with strabismus about treatment options. Which statement by the mother would indicate the need for further teaching? 1. My child will outgrow this by the time he is 2 yr old and be able to see just fine 2. I will have my child wear an eye patch over the good eye to help strengthen the weak eye 3. If this eye patch does not work i know that we will have to do surgery to correct my child's crossed eyes 4. There are a few causes of this condition and they tell me my child has crossed eye because of a muscle imbalance
1. My child will outgrow this by the time he is 2 yr old and be able to see just fine
The nurse is assisting with gathering admission assessment data on a 2 yr old child who has been diagnosed with nephrotic syndrome. The nurse collects data knowing that which is a common characteristic associated with nephrotic syndrome? 1. Hypotension 2. Generalized edema 3. Increased urinary output 4. Frank, bright red blood in the urine
2. Generalized edema
The nurse reviews the home care instructions with a parent of a 3 yr old with pertussis. Which statement by the parent indicates a need for further teaching? 1. I know that my child will make a loud whooping sound 2. I understand this whooping cough is viral and I have to let it run its course 3. I understand that I need to watch for respiratory distress signs with pertussis 4. I can reduce the environmental factors that can trigger coughing, like dust and smoke
2. I understand this whooping cough is viral and I have to let it run its course
The nurse is reinforcing instruction to the parents of a child with scoliosis regarding the use of a brace. Which statement by a parent indicates the need for further teaching. 1. I need to have my child wear a soft fabric under the brace 2. I will apply lotion under the brace to prevent skin breakdown 3. I need to encourage my child to perform the prescribed exercises 4. I need to avoid applying powder under the brace because it will cake
2. I will apply lotion under the brace to prevent skin breakdown
The nurse is reviewing the record of a child with increased intracranial pressure and notes that the child has exhibited signs of decerebrate posturing. During data collection about the child, the nurse expects to note which characteristic of this type of posturing? 1. Flaccid paralysis of all extremities 2. Adduction of the arms at the shoulders 3. Rigid extension and pronation of the arms and legs 4. Abnormal flexion of the upper extremities and extension and adduction of the lower extremities
3. Rigid extension and pronation of the arms and legs
A PHCP prescribes an IV solution of 5% dextrose and half-normal saline (0.45%) with 40 mEq of potassium chloride for a child with hypotonic dehydration. The nurse performs which priority assessment before this IV prescription is initiated? 1.Obtains a weight 2. Takes the temperature 3. Takes the blood pressure 4. Checks the amount of urine output
4. Checks the amount of urine output
The nurse reinforces instructions to the parents of a child with sickle cell anemia regarding the precipitating factors related to pain crisis. Which, if identified by a parent as a precipitation factor, indicates the need for further teaching? 1. Stress 2. Trauma 3. Infection 4. Fluid overload
4. Fluid overload
