Peds ATI 2019 B, Peds- ATI Practice Exam A
A nurse is caring for a school-age child who is receiving a blood transfusion. Which of the following manifestations should alert the nurse to a possible hemolytic transfusion reaction?
Flank pain Rationale: The nurse should recognize that flank pain is caused by the breakdown of RBCs and is an indication of a hemolytic reaction to the blood transfusion.
A nurse is teaching the parent of an infant who has a Pavlik harness for the treatment of developmental dysplasia of the hip. The nurse should identify that which of the following statements by the parent indicates an understanding of the teaching?
"I will place my infant's diapers under the harness straps." Rationale: To prevent soiling of the harness, the parent should apply the infant's diaper under the straps.
A hospice nurse is caring for a preschooler who has a terminal illness. The father tells the nurse that he cannot cope anymore and has decided to move out of the house. Which of the following statements should the nurse make?
"Let's talk about some of the ways you have handled previous stressors in your life." Rationale: This statement offers a general lead to allow the parent to express their feelings and previous actions when faced with stressful situations. It also helps the parent to focus on ways that they can cope with the current situation.
A nurse is teaching the parent of a preschooler about ways to prevent acute asthma attacks. Which of the following statements by the parent indicates an understanding of the teaching?
"I should keep my child indoors when I mow the yard." Rationale: The nurse should instruct the parent to keep the preschooler indoors during lawn maintenance or when the pollen count is increased. Guarding against exposure to known allergens found outdoors, such as grass, tree, and weed pollen, will decrease the frequency of the preschooler's asthma attacks.
A nurse is teaching the parents of a school-age child who has a new diagnosis of osteomyelitis of the tibia. The nurse should identify that which of the following statements by the parents indicates an understanding of the teaching?
"My child will receive antibiotics for several weeks." Rationale: The nurse should instruct the parent that the child will receive antibiotic therapy for at least 4 weeks. Surgery might be indicated if the antibiotics are not successful.
A nurse is an emergency department is assessing a toddler who has Kawasaki disease. Which of the following findings should the nurse expect? (select all that apply.) a. increased temperature b. gingival hyperplasia c. xerophthalmia d. bradycardia e. cervical lymphadenopathy
A, C, E
A nurse is planning an educational program to teach parents about protecting their children from sunburns. Which of the following instructions should the nurse plan to include? a. "allow your child to play outside during the hours between 10:00am and 2:00pm." b. "choose a waterproof sunscreen with a minimum SPF of 15." c. "dress you child in loose weave polyester fabric prior to sun exposure." d. "reapply sunscreen every 4 hours."
B
A nurse is providing discharge teaching to the guardians of a toddler who had a lower leg cast applied 24 hours ago. The nurse should instruct the guardians to report which of the following findings to the provider? a. capillary refill time less than 2 seconds b. restricted ability to move the toes c. swelling of the casted foot when the leg is dependent d. pedal pulse +3 bilateral
B
A nurse is providing teaching to an adolescent about how to manage tinea pedis. Which of the following statements by the adolescent indicates an understanding of the teaching? a. "I should buy plastic shoes to wear at the swimming pool." b. "I should wear sandals as much as possible." c. "I should place the permethrin cream between my toes twice daily." d. "I should seal my nonwashable shoes in plastic bags for a couple of weeks."
B
A nurse is assessing an adolescent who received a sodium polystyrene sulfonate enema. Which of the following findings indicates effectiveness of the medication? a. reports an absence of nausea and vomiting b. reports experiencing an onset of loose stools within 15 minutes of administration c. serum potassium level 4.1 mEq/L d. blood pressure 86/52 mm Hg
C
A nurse is caring for a newly admitted school age child who has hypopituitarism. Which of the following medications should the nurse expect the provider to prescribe? a. Desmopressin b. Luteinizing hormone-releasing hormone c. Recombinant growth hormone d. Levothyroxine
C
A nurse is providing discharge teaching to the parent of a school age child who has moderate persistent asthma. Which of the following instructions should the nurse include? a. "you should give your child their salmeterol inhaler every 4 hours when they are having an acute episode of wheezing." b. "you should monitor your child's weight weekly while they are receiving inhaled corticosteroids therapy." c. "pulmonary function tests will be performed every 12-24 months to evaluate how your child is responding to therapy." d. "when using the peak expiratory flow meter, record your child's average of three readings."
C
A nurse is providing discharge teaching to the parent of an 18 month old toddler who has dehydration due to acute diarrhea. Which of the following statements by the parent indicates an understanding of the teaching? a. "I will offer my child small amounts of fruit juice frequently." b. "I will avoid giving my child solid foods until the diarrhea has stopped." c. "I will monitor my child's number of wet diapers." d. "I will give my child polyethylene glycol daily for 7 days."
C
A nurse is reviewing the dietary choices of an adolescent who has iron deficiency anemia. The nurse should identify that which of the following menu items has the highest amount of nonheme iron? a. 1/2 cup whole milk b. 1 cup orange juice c. 1/2 cup raisins d. 1 cup raw carrots
C
A school nurse is caring for a child following a tonic-clonic seizure. Which of the following actions should the nurse take first? a. check the child for a head injury b. observe for oral bleeding c. check the child's respiratory rate d. observe for extremity weakness
C
A nurse in an emergency department is caring for a school-age child who has appendicitis and rates their abdominal pain as 7 on a scale of 0 to 10. Which of the following actions should the nurse take?
Give morphine 0.05mg/kg IV Rationale: A pain level of 7 on a scale of 0 to 10 is considered severe. The nurse should administer an analgesic medication for pain relief.
A nurse is caring for an infant who has respiratory syncytial virus (RSV). Which of the following actions should the nurse implement for infection control?
Have a designated stethoscope in the infant's room. Rationale: The nurse should initiate droplet precautions for an infant who has RSV because the virus is spread by direct contact with respiratory secretions. Therefore, designated equipment, such as a blood pressure cuff and a stethoscope, should be placed in the infant's room.
A nurse is reviewing the laboratory report of a school-age child who is experiencing fatigue. Which of the following findings should the nurse recognize as an indication of anemia?
Hematocrit 28% Rationale: The nurse should recognize that this hematocrit level is below the expected reference range of 32% to 44% for a school-age child. The child can exhibit fatigue, lightheadedness, tachycardia, dyspnea, and pallor due to the decreased oxygen-carrying capacity.
A nurse is reviewing the lumbar puncture results of a school-age child suspected of having bacterial meningitis. Which of the following results should the nurse identify as a finding associated with bacterial meningitis?
Increased protein concentration Rationale: The nurse should identify that an increased protein concentration in the spinal fluid is a finding that can indicate bacterial meningitis.
A nurse is performing hearing screenings for children at a community health fair. Which of the following children should the nurse refer to a provider for a more extensive hearing evaluation? a. an 18 month old toddler who has unintelligible speech b. a 3 month old infant who has exaggerated startle response c. a 4 year old preschooler who prefers playing with others rather than alone d. an 8 month old infant who is not yet making babbling sounds
D
A nurse is planning care for a school age child who has a tunneled central venous access device. Which of the following interventions should the nurse include in the plan? a. use sterile scissors to remove the dressing from the site b. irrigate each lumen weekly with 10 ml of 0.9% sodium chloride solution when not in use c. access the site suing a noncoring angle needle d. use a semipermeable transparent depressing to cover the site
D
A school nurse is providing an in service for faculty about improving education for students who have ADHD. Which of the following statements by a faculty member indicates an understanding of the teaching? a. "I will plan to increase the amount of homework I assign to students who have ADHD." b. "I will give students who have ADHD the same amount of time as other students to complete tests." c. "I will allow students who have ADHD one rest break throughout the day." d. "I will teach challenging academic subjects to students who have ADHD in the morning."
D
The nurse is caring for a preschooler who has been receiving IV fluids via a peripheral IV catheter. When preparing to discontinue the IV fluids and catheter, which of the following actions should the nurse plan to take?
First, the nurse should turn off the IV pump. Next, the nurse should occlude the IV tubing, and then remove the tape securing the catheter. Last, the nurse should apply pressure over the catheter insertion site.
A nurse is caring for a preschooler whose father is going home for a few hours while another relative stays with the child. Which of the following statements should the nurse make to explain to the child when their father will return?
"Your daddy will be back after you eat." Rationale: Preschoolers make sense of time best when they can associate it with an expected daily routine, such as meals and bedtime. Therefore, the child comprehends time best when it is explained to them in relation to an event they are familiar with, such as eating.
A nurse is caring for a school age child who has primary nephrotic syndrome and is taking prednisone. Following 1 week of treatment, which of the following manifestations indicates to the nurse that the medication is effective? a. decreased edema b. increased abdominal girth c. decreased appetite d. increased protein in the urine
A
A nurse is caring for an infant who is receiving IV fluids for the treatment of Tetralogy of Fallot and begins to have a hypercyanotic spell. Which of the following actions should the nurse take? a. place the infant in a knee-chest position b. administer a dose of meperidine IV c. discontinue administration of IV fluids d. apply oxygen at 2L/min via nasal cannula
A
A nurse is monitoring the oxygen saturation level of an infant using pulse oximetry. The nurse should secure the sensor to which of the following areas on the infant? a. wrist b. great toe c. index finger d. heel
B
A nurse is creating a plan of care for a preschooler who has Wilms' tumor and is scheduled for surgery. Which of the following interventions should the nurse include? a. avoid palpating the abdomen when bathing the child before surgery b. refrain form auscultating the child's bowel sounds during the postoperative assessment c. encourage the child to play with other children on the unit prior to surgery d. explain to the child that their pain will be managed after the surgery
A
A nurse is caring for a toddler who has spastic (pyramidal) cerebral palsy. Which of the following findings should the nurse expect? (Select all that apply.)
-Ankle clonus -Exaggerated stretch reflexes -Contractures
A school nurse is preparing to administer atomoxetine 1.2 mg/kg/day PO to a school aged child who weights 75 lbs. Available is atomoxetine 40 mg/capsule. How many capsules should the nurse administer per day?
1 capsule
A nurse in a health department is caring for an emancipated adolescent who has an STI and is unaccompanied by a guardian. Which of the following actions should the nurse take? a. have the adolescent sign a consent form for treatment b. instruct the adolescent to return with a guardian c. obtain consent from the adolescent's guardian over the phone d. treat the adolescent without a consent form
A
A nurse is assessing an infant who has pneumonia. Which of the following findings is the priority for the nurse to report the provider? a. nasal flaring b. WBC count 11,300/mm^3 c. diarrhea d. abdominal distension
A
A nurse is assessing the pain level of a 3 year old toddler. Which of the following assessment scales should the nurse use? a. FACES b. Numeric c. CRIES d. Visual analog
A
A nurse is caring for a school age child who has diabetes mellitus and was admitted with a diagnosis of diabetic ketoacidosis. When performing the respiratory assessment, which of the following findings should the nurse expect? a. deep respirations of 32/min b. shallow respirations of 10/min c. paradoxic respirations of 26/min d. periods of apnea lasting for 20 seconds
A
A nurse is caring for a school age child who has peripheral edema. The nurse should identify that which of the following assessments should be performed to confirm peripheral edema? a. palpate the dorsum of the child's feet b. weigh the child daily using the same scale c. assess the child's skin turgor d. observe the child for periorbital swelling
A
A nurse is receiving change-of-shift report on four children. Which of the following children should the nurse see first?
A school-age child who has sickle cell anemia and reports decreased vision in the left eye. Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should determine the priority finding is a report of decreased vision in the left eye. This finding indicates that the child is experiencing a vaso-occlusive crisis and should be reported to the provider immediately. Therefore, the nurse should see this child first.
A nurse is assessing a school-age child immediately following a perforated appendix repair. Which of the following findings should the nurse expect?
Absence of peristalsis Rationale: The nurse should expect absence of peristalsis immediately following a perforated appendix repair, until the bowel resumes functioning.
A nurse is caring for a preschooler who is scheduled for hydrotherapy treatment for wound debridement following a burn injury. Which of the following actions should the nurse take prior to the procedure?
Administer an analgesic to the child. Rationale: Hydrotherapy for debridement of a wound is an extremely painful procedure which requires analgesia and/or sedation. When pain is controlled, it leads to reduced physiological demands on the body caused by stress and decreases the likelihood of children developing depression and post-traumatic stress disorder.
A nurse in an emergency department is caring for a school-age child who is experiencing an anaphylactic reaction. Which of the following is the priority action by the nurse?
Administer epinephrine IM to the child. Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority action is administering epinephrine IM to the child. During an anaphylactic reaction, histamine release causes bronchoconstriction and vasodilation. This is an emergency because ultimately this causes decreased blood return to the heart.
A nurse is preparing to administer an immunization to a 4-year-old child. Which of the following actions should the nurse plan to take?
Administer the immunization using a 24-gauge needle. Rationale: The nurse should administer an immunization for a 4-year-old child using a 22- to 25- gauge needle to minimize the amount of pain the child experiences.
A nurse is preparing an adolescent for a lumbar puncture. Which of the following actions should the nurse take?
Apply topical analgesic cream to the site 1 hr prior to the procedure. Rationale: The nurse should apply a topical analgesic to the lumbar site 1 hr prior to the procedure to decrease the adolescent's pain while the lumbar needle is inserted.
A nurse in an emergency department is caring for a school age child who has epiglottitis. Which of the following actions should the nurse take? a. obtain a throat culture form the child b. monitor the child's oxygen saturation c. put a warm mist humidifier in the child's room d. place the child in the supine position
B
A nurse in an emergency department is caring for a school age child who has sustained a minor superficial burn from fireworks on their forearm. Which of the following actions should the nurse take? a. administer the tetanus toxoid vaccine if more than 1 year since the prior dose b. apply an antimicrobial ointment to the affected area c. leave the burn area open to air d. place an ice pack on the affected area
B
A nurse is assessing a 6 month old infant during a well child visit. Which of the following findings should the nurse report to the provider? a. presence of a central incisor tooth b. presence of strabismus c. presence of an open anterior fontanel d. presence of external cerumen
B
A nurse is caring for a 10 year old child following a head injury. Which of the following findings should the nurse identify as an indication that the child is developing diabetes incipidus? a. urine specific gravity 1.045 b. sodium 155 mEq/L c. blood glucose 45 mg/dL d. urine output 35 mL/hr
B
A nurse is assessing a school age child who has an infratentorial brain tumor. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure? a. hypotension b. reports insomnia c. difficulty concentrating d. tachycardia
C
A nurse is assessing an 8 year old child who has early indication of shock. After establishing an airway and stabilizing the child's respirations, which of the following actions should the nurse take next? a. insert an indwelling urinary catheter b. measure weight and height c. initiate IV access d. maintain ECG monitoring
C
A nurse is admitting an infant who has intussesception. Which of the following findings should the nurse expect? (select all that apply) a. steatorrhea b. vomiting c. lethargy d. constipation e. weight gain
B, C
A charge nurse is preparing to make a room assignment for a newly admitted school age child. Which of the following considerations is the nurse's priority? a. length of stay b. treatment schedule c. disease process d. self-care ability
C
A nurse in a provider's office is caring for a school age child who has varicella. The parent asks the nurse when their child will no longer be contagious. Which of the following responses should the nurse make? a. "When your child no longer has an increased temperature." b. "Three days after you first noticed the rash appear on your child." c. "When you child's lesions are crusted, usually 6 days after they appear." d. "Two to three weeks, when your child's lesions completely disappear."
C
A nurse in an emergency department is assessing a 3 month old infant who has rotavirus and is experiencing acute vomiting and diarrhea. Which of the following manifestations should the nurse identify as an indication that the infant has moderate to severe dehydration? a. HR 124 b. increased tear production c. sunken anterior fontanel d. capillary refill 2 seconds
C
A nurse is creating a plan of care for a newly admitted adolescent who has bacterial meningitis. How long should the nurse plan to maintain the adolescent in droplet precautions? a. until the adolescent is afebrile b. for 7 days following admission to the facility c. until the adolescent has a negative blood culture d. for 24 hrs following initiation of antimicrobial therapy
D
A nurse is discussing organ donation with the parents of a school age child who has sustained brain death due to a bicycle crash. Which of the following actions should the nurse take first? a. inform the parents that written consent is required prior to organ donation b. provide written information to the parents about organ donation c. ask the provider to explain misconceptions of organ donation to the parents. d. explore the parents feelings and wishes regarding organ donation
D
A nurse in the emergency department is caring for a toddler who has a partial thickness burns on their right arm. Which of the following actions should the nurse take?
Cleanse the affected area with mild soap and water. Rationale: The nurse should wash the affected area with mild soap and water to remove any loose tissue that could cause infection.
A nurse is assessing a 4-year-old child at a well-child visit. Which of the following developmental milestones should the nurse expect to observe?
Cuts an outlined shape using scissors. Rationale: The nurse should recognize that an expected developmental milestone of a 4-year-old child is using scissors to cut out a shape.
A community health nurse is assessing an 18 month old toddler in a community day care. Which of the following findings should a nurse identify as a potential indication of physical neglect? a. resists having an axillary temperature taken b. exhibits withdrawal behaviors when their parent leaves c. has multiple bruises on their knees d. poor personal hygiene
D
A nurse is caring for a preschooler who has congestive heart failure. The nurse observes wide QRS complexes and peaked T waves on the cardiac monitor. Which of the following prescriptions should the nurse clarify with the provider? a. furosemide b. captopril c. regular insulin d. potassium chloride
D
A nurse is creating a plan of care for a child who has varicella. which of the following interventions should the nurse include? a. maintain the child's room temperature at 80 degrees F b. prepare the child for a lumbar puncture c. administer aspirin to the child for a temperature greater than 38.3 degrees C (101 degrees F) d. initiate airborne precautions for the child
D
A nurse in an urgent care clinic is assessing an adolescent who has an upper respiratory tract infection. Which of the following findings should the nurse identify as a manifestation of pertussis?
Dry, hacking cough Rationale: The nurse should identify that a dry, hacking cough is a manifestation of pertussis. This disease usually begins with indications of an upper respiratory tract infection, which includes a dry, hacking cough that is sometimes more severe at night.
A nurse is caring for a school-age child who is receiving cefazolin via intermittent IV bolus. The child suddenly develops diffuse flushing of the skin and angioedema. After discontinuing the medication infusion, which of the following medications should the nurse administer first?
Epinephrine Rationale: This child is most likely experiencing an anaphylactic reaction to the cefazolin. According to evidence-based practice, the nurse should first administer epinephrine to treat the anaphylaxis. Epinephrine is a beta adrenergic agonist that stimulates the heart, causes vasoconstriction of blood vessels in the skin and mucous membranes, and triggers bronchodilation in the lungs.
A nurse is admitting a school-age child who has Pertussis. Which of the following actions should the nurse take?
Initiate droplet precautions for the child. Rationale: The nurse should initiate droplet precautions for a child who has pertussis, also known as whooping cough. Pertussis is transmitted through contact with infected large-droplet nuclei that are suspended in the air when the child coughs, sneezes, or talks.
A nurse is planning care for a school-age child who is in the oliguric phase of acute kidney injury (AKI) and has a sodium level of 129 mEq/L. Which of the following interventions should the nurse include in the plan?
Initiate seizure precautions for the child. Rationale: A sodium level of 129 mEq/L indicates hyponatremia and places the child at increased risk for neurological deficits and seizure activity. The nurse should complete a neurologic assessment and implement seizure precautions to maintain the child's safety.
A nurse is assessing an infant who has a ventricular septal defect. Which of the following findings should the nurse expect?
Loud, harsh murmur Rationale: The nurse should expect to hear a loud, harsh murmur with a ventricular septal defect due to the left-to-right shunting of blood, which contributes to hypertrophy of the infant's heart muscle.
A nurse is caring for a 15 year-old client following a head injury. Which of the following findings should the nurse identify as an indication that the child is developing syndrome of inappropriate antidiuretic hormone secretion (SIADH)?
Mental confusion Rationale: A child who has a head injury can develop SIADH as a result of altered pituitary function, leading to an oversecretion of antidiuretic hormone. Oversecretion of antidiuretic hormone leads to a decrease in urine output, hyponatremia, and hypoosmolality due to overhydration. As the hyponatremia becomes more severe, mental confusion and other neurologic manifestations such as seizures can occur.
A nurse is preparing to collect a sample from a toddler for a sickle-turbidity test. Which of the following actions should the nurse plan to take?
Perform a finger stick. Rationale: The nurse should perform a finger stick on a toddler as a component of the sickle-turbidity test. If the test is positive, hemoglobin electrophoresis is required to distinguish between children who have the genetic trait and children who have the disease.
A nurse is assessing a school-age child who has meningitis. Which of the following findings is the priority for the nurse to report to the provider?
Petechiae on the lower extremities Rationale: The presence of a petechial or purpuric rash on a child who is ill can indicate the presence of meningococcemia. This type of rash indicates the greatest risk of serious rapid complications from sepsis and should be reported immediately to the provider.
A nurse is caring for a school-age child who has experienced a tonic-clonic seizure. Which of the following actions should the nurse take during the immediate postictal period?
Place the child in a side-lying position. Rationale: The nurse should place the child in a side-lying position to prevent aspiration.
A nurse is creating a plan of care for a school-age child who has heart disease and has developed heart failure. Which of the following interventions should the nurse include in the plan?
Provide small, frequent meals for the child. Rationale: The metabolic rate of a child who has heart failure is high because of poor cardiac function. Therefore, the nurse should provide small, frequent meals for the child because it helps to conserve energy.
A nurse is assessing a 3-year-old toddler at a well-child visit. Which of the following manifestations should the nurse report to the provider?
Respiratory rate 45/min Rationale: The nurse should identify that a respiratory rate of 45/min is above the expected reference range of 20 to 25/min for a 3-year-old toddler and can indicate respiratory dysfunction and acute respiratory distress. Therefore, the nurse should report this finding to the provider.
A nurse is planning care for a toddler who has a serum lead level of 4 mcg/dL. Which of the following actions should the nurse plan to take?
Schedule the toddler for a yearly rescreening. Rationale: The nurse should schedule the toddler for a lead level rescreening in 1 year and educate the family on ways to prevent exposure.
A nurse is caring for an adolescent who received a kidney transplant. Which of the following findings should the nurse identify as an indication the adolescent is rejecting the kidney?
Serum creatinine 3.0 mg/dL Rationale: Creatinine is a byproduct of protein metabolism and is excreted from the body through the kidneys. An elevated serum creatinine level, therefore, can be an indication that the kidneys are not functioning. The nurse should identify that the adolescent's serum creatinine level is higher than the expected reference range of 0.4 to 1.0 mg/dL for an adolescent and can indicate rejection of the kidney.
A nurse is reviewing the laboratory report of an infant who is receiving treatment for severe dehydration. The nurse should identify that which of the following laboratory values indicates effectiveness of the current treatment?
Sodium 140 mEq/L Rationale: The nurse should identify that a sodium level of 140 mEq/L is within the expected reference range of 134 to 150 mEq/L and indicates the current treatment regimen the infant is receiving for dehydration is effective.
A nurse in an emergency department is performing an admission assessment on a 2 week-old male newborn. Which of the following findings is the priority for the nurse to report to the provider?
Substernal retractions Rationale: When using the airway, breathing, and circulation approach to client care, the nurse should determine that the priority finding to report to the provider is substernal retractions. This finding indicates the newborn is experiencing increased respiratory effort, which could quickly progress to respiratory failure.
A charge nurse in an emergency department is preparing an in-service for a group of newly licensed nurses on the clinical manifestations of child maltreatment. Which of the following manifestations should the charge nurse include as suggestive of potential physical abuse?
Symmetric burns of the lower extremities Rationale: The nurse should include that symmetric burns to the lower extremities can indicate physical abuse. The patterns are usually characteristic of the method or object used, such as cigar or cigarette burns, or burns in the shape of an iron.
A nurse is assessing a toddler who has gastroenteritis and is exhibiting manifestations of dehydration. Which of the following findings is the nurses priority?
Tachypnea Rationale: When using the airway, breathing, and circulation approach to client care, the nurse's priority finding is the toddler's tachypnea. Tachypnea is a result of the kidneys being unable to excrete hydrogen ions and produce bicarbonate, which leads to metabolic acidosis.
The nurse is interviewing the parent of an 18-month-old toddler during a well-child visit. The nurse should identify that which of the following findings indicates a need to assess the toddler for hearing loss?
The toddler received tobramycin during a hospitalization 2 weeks ago. Rationale: The nurse should identify tobramycin as an aminoglycoside, which is an ototoxic medication that can cause mild to moderate hearing loss, and should assess the toddler for a hearing impairment.
A nurse in a provider's office if preparing to administer immunizations to a toddler during a well-child visit. Which of the following actions should the nurse plan to take?
Withhold the measles, mumps, and rubella (MMR) vaccine. Rationale: The nurse should recognize that an allergy to neomycin with an anaphylactic reaction is a contraindication for receiving the MMR vaccine. Clients who have a severe allergy to eggs or gelatin should not receive this vaccine.
A nurse is providing teaching to the parent of an infant who has diaper dermatitis. The nurse should instruct the parent to apply which of the following to the affected area?
Zinc oxide Rationale: Diaper dermatitis is a common inflammatory skin disorder caused by contact with an irritant such as urine, feces, soap, or friction, and takes the form of scaling, blisters, or papules with erythema. Providing a protective barrier, such as zinc oxide, against the irritants allows the skin to heal.
A nurse is teaching the guardian of a 6-month-old infant about car seat use. Which of the following statements by the guardian indicates an understanding of the teaching?
"I should secure the car seat using lower anchors and tethers instead of the seat belt." Rationale: Lower anchors and tethers, or the LATCH child safety seat system, should be used to secure an infant's car seat in the vehicle. This system provides anchors between the front cushion and the back rest for the car seat. Therefore, if this system is available, the seat belt does not have to be used.
A nurse is receiving change of shift report for four children. Which of the following children should the nurse assess first? a. a toddler who has a concussion and an episode of forceful vomiting b. an adolescent who has infective endocarditis and reports having a headache c. an adolescent who was placed into halo traction 1 hr ago and reports pain as 6 on a scale of 0-10 d. a school age child who has acute glomerulonephritis and brown-colored urine
A
A nurse is reviewing the laboratory results of a school age child who is 1 week postoperative following an open fracture repair. Which of the following findings should the nurse identify as an indication of a potential complication? a. erythrocyte sedimentation rate 10mm/hr b. WBC count 6200/mm^3 c. c-reactive protein 1.4mg/L d. RBC count 4.7 million/mm^3
A
A nurse is teaching a group of parents about infectious mononucleosis. Which of the following statements by a parent indicates an understanding the teaching? a. "Mononucleosis is caused by an infection with the Epstein-Barr virus." b. "Mononucleosis is a bacterial infection requiring 14 days of antibiotics." c. "A monospot is a throat culture used to diagnosis mononucleosis." d. "Children who get mononucleosis will need to refrain form sports for 6 months."
A
A nurse is teaching the guardian of a 6 month old infant about teething. Which of the following statements should the nurse make? a. "your baby might pull at their ears when they are teething." b. "rub your baby's gums with an aspirin to decrease discomfort." c. "place a beaded teething necklace around your baby's neck." d. "Your baby's upper middle teeth will erupt first."
A
A school nurse is assessing an adolescent who has scoliosis. Which of the following findings should the nurse expect?
A unilateral rib hump Rationale: When assessing an adolescent for scoliosis, the school nurse should expect to see a unilateral rib hump with hip flexion. This results from a lateral S- or C-shaped curvature to the thoracic spine resulting in asymmetry of the ribs, shoulders, hips, or pelvis. Scoliosis can be the result of a neuromuscular or connective tissue disorder, or it can be congenital in nature.
A nurse is providing dietary teaching to the guardian of a school age child who has cystic fibrosis. Which of the following statements should the nurse make? a. "You should offer your child high protein meals and snacks throughout the day." b. "You should decrease your child's dietary fat intake to less than 10% of their caloric intake." c. "You should restrict your child's calorie intake to 1200 per day." d. "you should give your child a multivitamin once weekly."
A
A nurse is planning an educational program for school age children and their parents about bicycle safety. Which of the following information should the nurse plan to include? a. the child should be able to stand on the balls of their feet when sitting on the bike b. the child should ride their bike 2 feet to the side of other bike riders c. the child should wear dark colored clothing with a fluorescent stripe when riding at night d. the child should ride the bike facing traffic when it is necessary to tide in the street
A
A nurse is planning developmental activities for a newly admitted 10 year old child who has neutropenia. Which of the following actions should the nurse plan to take? a. provide the child with a book about adventure b. arrange frequent visits from family members and peers c. give the child a large piece puzzle d. use puppets to entertain the child
A
A nurse is caring for a toddler who has acute otitis media and a temperature of 40 degree C (104 degrees F). After administering acetaminophen, which of the following actions should the nurse plan to take to reduce the toddler's temperature? a. apply a cooling blanket to the toddler b. dress the toddler in minimal clothing c. give the toddler a tepid bath d. administer diphenhydramine to the toddler
B
A nurse is providing teaching to the family of a school-age child who has juvenile idiopathic arthrisis. Which of the following instructions should the nurse include in the teaching? a. "limit movement of the child's large joints" b. "encourage the child to perform independent self-care." c. "provide the child with a soft mattress for sleeping." d. "schedule a 2 hour daily nap for the child in the afternoon."
B
A nurse is providing teaching to the parents of a preschooler who has heart failure and a new prescription for digoxin twice daily. Which of the following instructions should the nurse include in the teaching? a. "Use a kitchen teaspoon to measure the medication." b. "Brush the child's teeth after giving the medication." c. "double the next dose if the child misses a dose." d. "repeat the dose if the child vomits."
B
A nurse is teaching the parents of a toddler who has a cognitive impairment about toilet training. Which of the following instructions should the nurse include in the teaching a. "scold your child when they have toileting accident." b. "award your child with a sticker when they sit on the potty chair." c. "play your child's favorite song while teaching them to use the potty chair." d. "teach multiple steps of the skill at the same time."
B
A nurse is caring for a 1 month old infant who is breastfeeding and requires a heel stick. Which of the following actions should the nurse take to minimize that infant's pain? a. Use a manual lancet to obtain the heel blood sample b. apply an ice pack to the infant's heel prior to obtaining the sample c. allow the mother to breastfeed while the sample is being obtained d. apply a topical lidocaine cream prior to obtaining the sample
C
A nurse is providing discharge teaching to the guardian of a school age child who has undergone a tonsillectomy. Which of the following statements by the guardian indicates an understanding the teaching? a. "my child can resume usual activities since this year just an outpatient surgery." b. "my child will be able to drink the chocolate milkshake I promised to get for them tonight." c. "I will notify the doctor if I notice that my child is swallowing frequently." d. "I will have my child gargle with warm salt water to relieve their sore throat."
C
A nurse is teaching a school age child and their parent about postoperative care following cardiac catheterization. Which of the following instructions should the nurse include? a. "Stay home from school for 1 week following the procedure." b. "follow a diet that is low in fiber for 1 week." c. "wait 3 days before taking a tub bath." d. "apply a pressure dressing to the site for 3 days."
C
A nurse is planning care for a newly admitted school age child who has generalized seizure disorder. Which of the following interventions should the nurse plan to include? a. ensure that a padded tongue blade is at the child's bedside b. allow the child to play video games on a tablet computer c. allow the child to take a tub bath independently d. ensure the oxygen source is functioning in the child's room
D
A nurse is planning care to address nutritional needs for a preschooler who has cystic fibrosis. Which of the following interventions should the nurse include in the plan? a. administer pancreatic enzymes 2 hours after meals b. discontinue the use of pancreatic enzymes if steatorrhea develops c. limit fluid intake to 750 mL per day d. increase fat content in the child's diet to 40% of total calories.
D
A nurse is providing anticipatory guidance to the parent of a toddler. Which of the following expected behavior characteristics of toddlers should the nurse include? a. controls impulsive feelings b. understands right from wrong c. easily separates from parents for long periods of time d. expresses likes and dislikes
D
A nurse is providing discharge teaching to he parents of a 3 month old infant following a cheiloplasty. Which of the following instructions should the nurse include? a. "clean your baby's sutures daily with a mixture of chlorhexidine and water." b. "expect your baby to swallow more than usual over the next few days." c. "inspect your baby's tongue for white patches using a tongue depressor every 8 hours." d. "apply a thin layer of antibiotic ointment on your baby's suture line daily for the next 3 days."
D
A nurse is providing discharge teaching to the parents of a 6 month old infant who is postoperative following hypospadias repair with a stent placement. Which of the following instructions should the nurse include in the teaching? a. "you may bathe your infant in an infant bathtub when you go home." b. "apply hydrocortisone cream to your infant's penis daily." c. "you should clamp your infant's stent twice daily." d. "allow the stent to drain directly into your infant's diaper."
D
A nurse is caring for a school-age child who is receiving chemotherapy and is severely immunocompromised. Which of the following actions should the nurse take?
Screen the child's visitors for indications of infection. Rationale: A child who is severely immunocompromised is unable to adequately respond to infectious organisms, resulting in the potential for overwhelming infection. Therefore, the nurse should screen the child's visitors for indications of infection.
