Peds exam 2

* A nurse is caring for a toddler who has intussusception. Which of the following manifestations should the nurseexpect? A. Drooling B. Increased appetite C. Jaundice D. Mucus in stools

D. Mucus in stools Rationale:Stools with mucus and blood are manifestations of intussusception.

A nurse is assisting with the care of a school-aged child who has skeletal traction applied to repair a pelvic fracture. Which of the following actions should the nurse take? A. Rest the child's traction weights on the floor for 8 hours during the night B. Ensure the child's meal tray contains no high-fiber foods C. Perform passive range-of-motion exercises on the involved joints every 4 hours D. Place the child on a pressure-reduction mattress

D. Place the child on a pressure-reduction mattress

A nurse is providing care for an infant following a surgical repair of a cleft lip. Which of the following actions should the nurse take to minimize the infant's crying? A. Offer the infant a pacifier B. Position the infant on the abdomen C. Place the infant in a playpen at the nurses' station D. Rock the infant with a favorite blanket.

D. Rock the infant with a favorite blanket.

A nurse is preparing to reinforce teaching with a client who has a new diagnosis of type 2 diabetes mellitus. Which of the following actions is the nurse's priority in contributing to this plan? a. Establish short-term, realistic goals for the client. b. Give the client access to a video about diabetes. c. Determine what the client knows about managing her diabetes. d. Evaluate the effectiveness of the client's admission teaching plan.

c. Determine what the client knows about managing her diabetes.

1. A female teen volunteer is assigned to the pediatric unit for the day and reports to the charge nurse for an assignment. Which of the following assignments is unsafe for the volunteer? a. Reading a book to a 4 year old client who has AIDS b. Refilling the ice pitchers for clients on the unit for the charge nurse c. Helping a 7 year old who has celiac disease make out the next day's menu d. Playing a computer game with a 15 year old male client in skeletal traction

c. Helping a 7 year old who has celiac disease make out the next day's menu

1. A nurse is caring for a client who has a prescription for balanced skeletal traction with a Thomas splint of the treatment of a fractured femur. Which of the following interventions should the nurse implement to prevent pressure points from developing around the edges of the splint? a. Remove the weights for a few minutes each hour b. Apply lotion to the skin under the edges of the splint c. Reposition the client to keep him from staying in the same position in bed d. Apply a foot plate to the bed

c. Reposition the client to keep him from staying in the same position in bed

A nurse is reinforcing teaching with a school-aged child who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements should the nurse make? A. "If you take too much insulin, drink a sugar-free cola." B. "You will need to decrease your insulin dosage when you become a teenager." C. "You can use a vial of insulin for up to 30 days." D. "Stop taking your insulin if you are vomiting."

C. "You can use a vial of insulin for up to 30 days." The child can use an opened vial of insulin for 28 to 30 days stored at room temperature or in the refrigerator.

* A nurse is contributing to the plan of care for a 2-month-old infant who has just undergone cleft palate repair. The nurse should contribute which of the following interventions to the client's plan of care?​ a. Feed the infant half-strength formula for the first 48 hr. b. Remove elbow restraints while the infant is sleeping. c. Keep the infant in a side-lying position. d. Administer pain medication PRN for the first 48 hr.

c. Keep the infant in a side-lying position.

A nurse is preparing to feed an infant who has a cleft lip and palate. Which of the following actions should the nurse plan to take? A. Burp the infant at least 2 to 3 times during the feeding B. Remove the nipple from the infant's mouth if swallowing becomes audible C. Stop the feeding if formula appears in the nasal cavity of the infant D. Discourage the parents from participating in the feeding prior to a surgical repair

A. Burp the infant at least 2 to 3 times during the feeding Infants who have a cleft lip and palate will swallow an increased amount of air during a feeding due to a lack of separation between the oral and nasal cavities. Infants should be burped after every ounce of formula consumed.

A nurse is assisting with a routine physical examination of an adolescent. The provider observes a lateral curvature of the spine. The nurse should expect the provider to document which of the following disorders? A. Scoliosis B. Kyphosis C. Lordosis D. Torticollis

A. Scoliosis

A 14-year-old female will receive a Milwaukee brace to correct scoliosis with a 24 degree curve. Reviewing her discharge instructions, the nurse recognizes that the client has received adequate teaching when she says she will A. Wear the brace all day and remove it only to bathe. B. Put the brace on a minimum of one hour, three times per day. C. Wear the brace after school and at night. D. Take off the brace if her skin gets sore or starts to break down.

A. Wear the brace all day and remove it only to bathe.

A nurse on a pediatric unit receives the laboratory results for several clients. Which of the following results should the nurse report to the provider? A. A client who has bacterial pneumonia and a WBC count of 15,800/mm^3 B. A client who has chronic kidney disease and a calcium level of 8.7 mg/dL C. A client who has diabetic ketoacidosis and a blood glucose of 375 mg/dL D. A client who has leukemia and a hematocrit of 32%

C. A client who has diabetic ketoacidosis and a blood glucose of 375 mg/dL The initial goal of therapy for diabetic ketoacidosis (DKA) is reaching a blood glucose level below 240 mg/dL. To accomplish this, the client should receive regular insulin via continuous IV infusion, and the nurse should monitor the client's blood glucose level hourly. The nurse should report the client's result so that the provider can adjust the insulin dosage.

A nurse is caring for a child who has type 1 diabetes mellitus. Which of the following manifestations of diabetic ketoacidosis? Select all that apply. A. Blood glucose 58 mg/dl. B. Weight gain. C. Dehydration. D. Mental confusion. E. Fruity breath.

C. Dehydration. D. Mental confusion. E. Fruity breath

A nurse is caring for a toddler who is diagnosed with hip dysplasia and has been placed in a hip spica cast. The child's mother asks the nurse why a Pavlik harness is not being used. Which of the following responses by the nurse appropriately addresses the mother's question? A. "The Pavlik harness is used for children with scoliosis, not hip dysplasia." B. "The Pavlik harness is used for school-age children." C. "The Pavlik harness cannot be used for your child because her condition is too severe." D. "The Pavlik harness is used for infants less than 6 months of age."

D. "The Pavlik harness is used for infants less than 6 months of age."

A nurse is caring for a 7 year old child who has an upper respiratory infection and type 1 diabetes. Which of the following statements by the mother indicates a need for further teaching a. "I will encourage her to drink a half cup of water or sugar free fluids every 30 minutes" b. "I will report a change in her breathing or signs of confusion" c. "I will notify the doctor if her temperature is not controlled with acetaminophen" d. "I will continue to check his blood sugar 2 times per day:

d. "I will continue to check his blood sugar 2 times per day: A client who has type 1 diabetes mellitus and is ill is at risk of developing DKA. DKA results in the breakdown of body fat for energy and the presence of ketones in the blood and urine. Because acute illness increases glucose levels, the child's glucose levels and the urine ketones should be checked every 3 hr. Checking the child's blood glucose two times per day is not enough to adequately monitor glucose levels.

Which of the following would be the priority nursing diagnosis related to a severe curvature scoliosis patient? A) Impaired breathing due to inadequate chest expansion B) Disturbed body image C) Deficit knowledge related to surgical procedure D) Promotion of developmental tasks

A) Impaired breathing due to inadequate chest expansion

... baby with clubfoot who has had a cast applied. The nurse should provide additional teaching to the parents if they state: 1."I should call if I see changes in the color of the toes under the cast." 2."I should use a pillow to elevate my child's foot as he sleeps." 3."My baby will need a series of casts to fix her foot." 4."Having a cast should not prevent me from holding my baby.

"I should use a pillow to elevate my child's foot as she sleeps" Elevating the extremity at different points during the day is helpful to prevent edema, but pillows should not be used in the crib because they increase the risk of sudden infant death syndrome (SIDS)

** Which would the nurse expect to assess on a 3-week-old infant with developmental dysplasia of the hip (DDH)? Select all that apply. 1. Excessive hip abduction. 2. Femoral lengthening of an affected leg. 3. Asymmetry of gluteal and thigh folds. 4. Pain when lying prone. 5. Positive Ortolani test

** Asymmetry of gluteal and thigh folds. 5. Positive Ortolani test 1. In DDH, a newborn can have excessive hip adduction.2. In DDH, an appearance of femoral shortening is frequently present on the affected side.3. In DDH, asymmetrical thigh and gluteal folds are frequently present.4. Infants do not experience pain from this condition.5. The Ortolani maneuver moves a disclocated hip back into the socket with a distinct clunk.

** The nurse is teaching family members how to care for their infant in a Pavlik harness to treat congenital developmental dysplasia of the hip. The nurse should include in the parental education to A. Apply lotion or powder to minimize skin irritation. B. Put clothing over the harness for maximum effectiveness of the device. C. Check at least two or three times a day for red areas under the straps. D. Place a diaper over the harness, preferably using a thin superabsorbent disposable diaper.

** C. Check at least two or three times a day for red areas under the straps.

... Teaching an adolescent who has diabetes mellitus about manifestations of hyperglycemia. Select all that apply.

- Increased urination - Hunger - Dark yellow-colored urine

A nurse is planning care of a child who has a urinary tract infection. Which of the following interventions should the nurse include?

- encourage frequent voiding

A nurse is teaching a parent of a child who has a urinary tract infection. Which of the following should the nurse include in the teaching?

-Avoid bubble baths -Empty bladder completely with each void -Watch for manifestations of infection

A home health nurse is developing a plan of care for a child who has hemiplegic cerebral palsy. Which of the following goals is the priority for the nurse to include in the plan of care?

-Modify the environment

** The pediatric nurse is caring for a neonate with congenital clubfoot. The child has a cast to correct the defect. Before discharge, what should the nurse tell the parents? A. The cast will be removed in 6 weeks. B. A new cast is needed every week. C. A short leg cast is applied when the baby is ready to walk. D. The cast will be removed when the baby begins to crawl. E. A foot abduction brace is applied after the first week of casting.

B. A new cast is needed every week.

A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions is the nurse'spriority? A. Place the child on a no-salt-added diet. B. Check the child's weight C. Educate the parents about potential complications.ht daily. D. Maintain a saline-lock.

B. Check the child's weight Rationale: The first action the nurse should take using the nursing process is to collect data. Therefore,checking the child's weight daily is the priority.

A nurse is developing a plan of care for a toddler who has cerebral palsy. Which of the following actions should the nurse include? A. Structure interventions according to the chronological age. B. Evaluate the toddler's need for an evaluation of hearing ability. C. Monitor the toddler's pain level routinely using a numeric rating scale. D. Provide total care for daily hygiene activities.

B. Evaluate the toddler's need for an evaluation of hearing ability. The nurse should recognize that the toddler who has CP has an increased risk for hearing impairment; therefore, the nurse should evaluate the toddler's need for an evaluation of hearing ability.

A nurse is caring for a male infant who has a palpable mass in the upper right quadrant and stools mixed with blood and mucus. The nurse should recognize that which of the following diagnoses is associated with these findings? A. Hypertrophic pyloric stenosis B. Intussusception C. Inguinal hernia D. Tracheoesophageal fistula

B. Intussusception

A nurse is assessing an infant who has a suspected urinary tract infection. Which of the following are anticipated findings? (Select all that apply.) A. Increase in hunger B. Irritability C. Decrease in urination D. Vomiting E. Fever

B. Irritability D. Vomiting E. Fever

A nurse is assessing a child who has a urinary tract infection. Which of the following are clinical manifestations of a urinary tract infection? (Select all that apply.) A. Night sweats B. Swelling of the face C. Pallor D. Pale colored urine E. Fatigue

B. Swelling of the face C. Pallor E. Fatigue

A nurse is planning care for an adolescent who has scoliosis and requires surgical intervention. Which of the following behaviors by the adolescent should the nurse anticipate because it is most common reaction?

Body image changes

* A nurse is contributing to the plan of care of a 14-month-old toddler who is 24 hr postoperative following a cleftpalate repair. Which of the following interventions should the nurse include in the plan? A. Provide soft foods for the toddler. B. Suction the toddler nose and mouth every hour. C. Maintain elbow restraints on the toddler. D. Give the toddler a hard-tipped sippy cup to drink liquids

C. Maintain elbow restraints on the toddler. Rationale: The nurse should maintain elbow restraints on the toddler to prevent touching of the mouth.The nurse should monitor the skin under the restraints and remove the restraints periodicallyto allow the toddler to exercise his arms.

A nurse is caring for an 18-month-old infant who has chronic otitis media. The nurse should recognize that chronic otitis media will affect which of the following? A. Olfaction B. Visual acuity C. Speech patterns D. Hand-eye coordination

C. Speech patterns The nurse should recognize that chronic otitis media can result in hearing loss, which can affect speech development.

* A nurse in a clinic is teaching a group of parents about scoliosis screening. Which of the following statements by a parent indicates an understanding of the teaching? a. "During the screening, the child is asked to stand and bend forward at the waist with his arms hanging." b. "Boys should be screened for scoliosis at a younger age than girls." c. "Children who have scoliosis will often report back pain." d. "Scoliosis is associated with some form of childhood trauma."

a. "During the screening, the child is asked to stand and bend forward at the waist with his arms hanging."

A nurse is caring for a preschool-aged child who has an intussusception of the bowel. Which of the following findings should the nurse report to the physician?

Passage of a formed brown stool

* A nurse is providing teaching to a parent of a child who has celiac disease. The nurse should include which of the following food choices for this child? Rye Wheat Barley Rice

Rice

A nurse is collecting data from a school-aged child who has celiac disease. Which of the following findings should the nurse expect? a) Elevated sweat chloride b) Steatorrhea c) Clubbed fingers d) Jaundice

Steatorrhea

1. A nurse is caring for an adolescent who has spina bifida and is paralyzed from the waist down. Which of the following statements by the client would indicate to the nurse a need for further teaching? a. "I only need to catheterize myself twice every day." b. "I only use a suppository every night to have a bowel movement." c. "I do wheelchair exercises while watching TV." d. "I carry a water bottle with me because I drink a lot of water."

a. "I only need to catheterize myself twice every day." Should cath q4 hrs to prevent urinary stasis

... nursing instructions: 13-year-old female with scoliosis who is discharged with a ... brace?

Wear a cotton t-shirt underneath the brace

... Child with diabetes mellitus, nutrition and medication... teaching?

You should give four or five injections around one area before switching sites

A nurse is teaching the parent of a school-age child who has celiac disease. Which of the following foods selected by the parent indicates an understanding of the teaching? a) Corn tortilla w/ black beans b) Pizza c) Canned soup d) Hot dogs

a) Corn tortilla w/ black beansPizza, bread, and anything processed has gluten. Corn and beans are gluten-free

A 11-year-old girl gets diagnosed with idiopathic scoliosis and must wear a Milwaukee Brace what statement shows the nurse that the parents understands what to look for and how to properly use the brace? Select all that apply a) I will try to keep my daughter's self-esteem up knowing it might go down while wearing this brace b) I will let her take it off when she is at school and hanging out with her friends all day to keep her confidence c) I will make sure she wears it for the time the doctor tells her to even though it might range from 16-23 hours a day d) I will let her wear it under her cloths to protect her dignity

a) I will try to keep my daughter's self-esteem up knowing it might go down while wearing this brace c) I will make sure she wears it for the time the doctor tells her to even though it might range from 16-23 hours a day Her self-esteem might go down while wearing the brace, but she should still wear it to prevent her scoliosis from getting worse. Talking it off during school is not a good idea since she has to wear it anywhere from 16-23 hours. Letting her wear, it under her clothes might seem like a really good idea to hide it but it can damage the skin by doing that.

1. A 6-month-old infant has had surgery to correct intussusception. The surgeon has prescribed clear liquids by mouth. The nurse correctly administers which of the following? a. Sterile water b. Oral electrolyte solution c. Full-strength orange juice d. Half-strength infant formula

b. Oral electrolyte solution

A nurse is reinforcing teaching about self-administration of insulin with a parent of a school-age child who has a new diagnosis of diabetes mellitus. Which of the following statements by the parent indicates a need for further teaching? a. "I will be sure my child aspirates before injecting the insulin." b. "The insulin can be injected anywhere there is adipose tissue." c. "I will be sure my child rotates sites after five injections in one area." d. "The insulin should be injected at a 90-degree angle."

a. "I will be sure my child aspirates before injecting the insulin."

1. A nurse is providing teaching to a parent of a child who has a fracture of an epiphyseal plate. Which of the following statements should the nurse make? a. "Normal bone growth can be affected." b. "The blood supply to the bone is disrupted." c. "Bone marrow can be lost through the fracture." d. "The younger the child the longer the healing process will take."

a. "Normal bone growth can be affected."

1. A nurse is caring for a school age child with acute glomerulonephritis who has peripheral edema and is producing 35 mL of urine per hour. The child should be placed on which of the following diets? a. Low-sodium, fluid-restricted b. Low-carbohydrate, low-protein diet c. Low-protein, low-potassium diet d. Regular diet, no added salt

a. Low-sodium, fluid-restricted

* A nurse is caring for a child who is having a seizure. Which of the following actions should the nurse take? (Select all that apply) a. Place the client in a side lying position b. Assess the client's airway patency c. Restrain the client d. Remove objects from the client's bed

a. Place the client in a side-lying position b. Assess the client's airway patency d. Remove objects from the client's bed

What symptoms of would be an indication of scoliosis during a screening? Select all that apply. a) Both arms are the same length when child is bending forward b) The arm-to-body spaces may be unequal c) Pain in and around the spined D) scapula may be prominent

b) The arm-to-body spaces may be unequal D) scapula may be prominent The arm-to-body spaces may be unequal and a scapula may be prominent. One arm may appear longer than the other arm when bending forward. Symptoms develop slowly and are not painful.

A nurse if providing teaching to a school-age child who has a new diagnosis of type 1 diabetes. Which of the following statements by the child indicates an understanding of the teaching? a. "my morning blood glucose should be between 90 and 130" b. "I should eat a snack half an hour before playing soccer" c. "I should not take my regular insulin when I am sick." d. "I can store unopened bottles of insulin in the freezer".

b. "I should eat a snack half an hour before playing soccer"

A nurse is providing discharge teaching to the parents of a child who has a new diagnosis of diabetes. Which of the following statements by the parents indicates and understanding of the teaching? a. "the onset of low blood glucose usually occurs slowly" b. "my son may complain of feeling shaky when he has low blood glucose" c. "sweating can occur with hyperglycemia" d. "my son might have nausea and vomiting with hypoglycemia"

b. "my son may complain of feeling shaky when he has low blood glucose"

A nurse reinforces teaching with a client about dietary choices for celiac disease. Which of the following menu choices selected by the client indicates an understanding of the teaching? a. Hamburger on a wheat bun b. Baked chicken and potato chips c. Bacon, lettuce, and tomato sandwich on rye toast d. Beef and barley soup with rice crackers

b. Baked chicken and potato chips

* A nurse is planning care for an infant who has spina bifida and is to undergo surgical. Which of the following interventions should the nurse include in the plan of care? a. Maintain the infant in the supine position b. Provide a latex-free environment c. Limit visitors to immediate family members d. Initiate contact precautions

b. Provide a latex-free environment

A nurse is caring for a child who has enuresis. Which of the following is a complication of enuresis? a. UTI's b. emotional problems c. urosepsis d. progressive kidney disease

b. emotional problems

which of the following may cause conductive hearing impairment a. ototoxic drugs b. otitis media c. meningitis d. exposure to loud noises

b. otitis media

** a nurse is caring fro a child who has otitis media. which of the following assessment findings should the nurse expect A. Clear drainage from the affected ear b. tugging on the affected ear lobe c. pain when manipulating the affected ear lobe d. erythema and edema of the affected ear

b. tugging on the affected ear lobe

A nurse is reinforcing teaching with an adolescent who has type 1 diabetes mellitus. Which of the following instructions should the nurse include in the teaching? a. Administer glucagon for hyperglycemia. b. ​Obtain an influenza vaccine annually. c. ​Inject insulin in the deltoid muscle. d. Take glyburide with breakfast.

b. ​Obtain an influenza vaccine annually.

Parents bring their 3 month old bby into the ED. They say that the baby has been projectile vomiting then drinking hella right after throwing up. What does this sound like? a) Intussusception b) Kawasaki disease c) Pyloric stenosis d) Reyes

c) Pyloric stenosis

A nurse is creating a plan of care for an 18-month-old toddler who has cerebral palsy. Which of the following interventions should the nurse include?a) Use a mobile walker for the toddler b) Discourage activities involving repetitive joint movement c) Use manual jaw control when feeding toddler d) Discourage use of wrist splints

c) Use manual jaw control when feeding toddler Peeps with cerebral palsy can lose jaw control, and more effective control can be achieved by providing stability to jaw during feeding.

1. A nurse is completing discharge teaching to a parent of a child with a new diagnosis of diabetes mellitus. Which of the following statements by the parent requires clarification of the teaching? a. "The onset of low blood glucose usually occurs rapidly." b. "Sweating can occur with hypoglycemia." c. "My son may be very thirsty or have fruity breath when hypoglycemic." d. "My son may complain of feeling shaky when he has a low blood glucose level."

c. "My son may be very thirsty or have fruity breath when hypoglycemic."

1. A nurse is reviewing data for four children. Which of the following children should the nurse assess first? a. A 4 year old child who has asthma and a PCO2 of 37 mm Hg b. A 7 year old child who has diabetes insipidus and a urine specific gravity of 1.000 c. A 10 year old child who has sickle cell anemia who reports severe chest pain d. A 1-year-old toddler who has roseola and temperature of 38° C

c. A 10 year old child who has sickle cell anemia who reports severe chest pain

A nurse is assisting with the admission of a 2-year-old toddler who has acute gastroenteritis. Which of the following actions should the nurse take first? a. Initiate isotonic fluids with 20 mEq/L potassium chloride. b. Request evaluation of the toddler's serum electrolytes. c. Determine if the toddler is voiding. d. Collect a stool sample from the toddler.

c. Determine if the toddler is voiding. Rationale: The first action the nurse should take when using the nursing process is assessment. Thenurse should first determine if the toddler is voiding before proceeding further with any otherinterventions.

* A nurse is assisting with the care of a child who has spina bifida. Which of the following precaution should the nurse take while caring for this child? a. Seizure precautions b. Contact precautions c. Latex precautions d. Neutropenic precautions

c. Latex precautions

1. A nurse is preparing to apply a cast to a preschooler's arm. Which of the following shouldthe nurse do? a. Place a heated fan at bedside to facilitate drying b. Tell the child, "This will make your arm feel better." c. Wrap the arm of the child's doll or toy prior to the procedure d. Support casted arm with a firm grasp

c. Wrap the arm of the child's doll or toy prior to the procedure (During this stage of development, the child is a "magical thinker" and might believe stuffed animals are alive. This action shows the child that it does not hurt the doll or stuffed animal, and, in turn, will not hurt the child.)

* A nurse is caring for a child who is experiencing a seizure. Which of the following actions should the nurse take? a. Elevate the child's legs on a pillow. b. Restrain the child's arms. c. Insert a padded tongue blade into the child's mouth. d. Place the child in a side-lying position.

d. Place the child in a side-lying position.

* A nurse is assessing an 8-month old infant for cerebral palsy. Which of the following findings is a manifestation of the condition?

sits with pillow props

* A nurse is teaching an adolescent client who has type 1 diabetes mellitus about managing hypoglycemia. Which of the following statements should the nurse include in the teaching?"If you experience hypoglycemia you should..." a) drink 8oz of regular pop b) drink 4oz OJ c) take 2 glucose tablets d) take 3 tsp of sugar

b) drink 4oz Orange juice

1. A parent calls a clinic and reports to a nurse that his 2 old infant is hungry more than usual but is projectile vomiting immediately after eating. Which of the following responses should the nurse make? a. "Try switching to a different formula." b. "Bring your baby in to the clinic today." c. "Give your infant an oral rehydration solution." d. "Burp your baby more frequently during feedings."

b. "Bring your baby into the clinic today." Rationale: The nurse should recognize that projectile vomiting, followed by the child acting hungry afterward, are indicative of pyloric stenosis. The infant needs to be examined in the clinic as soon as possible by the provider.

12 month old infant ... 6 hours postoperative following cleft repair. Which interventions should the nurse include in the infant's plan of care? Select all that apply.

- Apply and release elbow restraints every hour - Encourage the parents to rock the infant

... Child who has cerebral palsy experiencing painful muscle spasms. Which of the following medications should the nurse administer?

- Baclofen Baclofen muscle relaxant to help ease those painful muscle spasms.

A nurse is teaching a school-age child who has diabetes mellitus about insulin administration. Which of the following should the nurse include in the teaching? A. "You should inject the needle at a 30-degree angle." B. "You should combine your glargine and regular insulin in the same syringe." C. "You should aspirate for blood before injecting the insulin." D. "You should give four or five injections in one area before switching sites."

D. "You should give four or five injections in one area before switching sites."

A nurse is caring for a toddler who has otitis media and a temperature of 39.1°C (102.4°F). Which of the following actions should the nurse take first? A. Reduce the temperature of the child's room B. Redress the child in minimal clothing C. Apply cool compresses to the child's forehead D. Administer an antipyretic to the child

D. Administer an antipyretic to the child When using the urgent vs. nonurgent approach to client care, the nurse should first administer an antipyretic to decrease the toddler's body temperature.

A nurse is reinforcing teaching with a parent of an infant who has gastroesophageal reflux. Which of the followingstatements by the parent indicates an understanding of the teaching? A. "I will keep my baby in an upright position after feedings." B. "My baby's formula can be thickened with oatmeal." C. "I will have to feed my baby formula, rather than breast milk." D. "I should move my baby into a side-lying position during sleep."

A. "I will keep my baby in an upright position after feedings." Rationale: The infant should be maintained in an upright position for 1 hr after feedings.

* A nurse is caring for an infant who is 1 day postoperative following surgical repair of a cleft lip. Which of thefollowing actions should the nurse take? A. Apply an antibiotic ointment to the suture site. B. Clear oral secretions using a bulb syringe. C. Feed the infant using a spoon. D. Position the infant on her abdomen.

A. Apply an antibiotic ointment to the suture site. Rationale: The nurse should apply an antibiotic ointment to the suture site to help prevent a postoperative infection

A nurse is discussing the causes of chronic diarrhea with a client. Which of the following conditions is caused by malabsorption? A. Celiac disease B. Ulcerative colitis C. Hirschsprung's disease D. Crohn's disease

A. Celiac disease

A nurse is caring for a school-aged child who begins to have a tonic-clonic seizure when leaving the bathroom. Which of the following actions should the nurse take first? A. Obtain a portable suction machine and suction tubing B. Ease the child to the floor in Sims' position C. Time the length of the seizure D. Notify the child's parents

B. Ease the child to the floor in Sims' position The greatest risk to the child is an injury resulting from a fall; therefore, the nurse should gently ease the child onto the floor to decrease the chance of injury and turn the child on her left side to prevent aspiration.

A nurse is caring for a newborn who has spina bifida. The newborn's parents are upset by the diagnosis. Which of the following actions should the nurse take? A. Discuss placement options for the newborn B. Encourage the parents to touch and care for the newborn C. Reassure the parents that everything will be fine D. Avoid talking about the newborn's defect until the parents bring up the subject

B. Encourage the parents to touch and care for the newborn

A nurse is teaching a child who has type 1 diabetes mellitus about self-care. Which of the following statements by the child indicates understanding of the teaching? A. "I should skip breakfast when I am not hungry." B. "I should increase my insulin with exercise." C. "I should drink a glass of milk when I am feeling irritable." D. "I should draw up the NPH insulin into the syringe before the regular insulin."

C. "I should drink a glass of milk when I am feeling irritable."

A nurse is assisting with the plan of care for a child who has meningococcal meningitis. Which of the following isolation precautions should the nurse plan to implement? A. Airborne precautions B. Contact precautions C. Protective environment D. Droplet precautions

D. Droplet precautions ****the client should take antibiotics and should be put in contact and droplet precautions The nurse should maintain droplet precautions for a client who has meningococcal meningitis for 24 to 72 hours after the initiation of antibiotic therapy. Disease transmission can occur through large-droplet particles when the client is talking. There is no drainage of infected body fluids with meningitis, so contact precautions are not necessary.

What are some expected findings of cerebral palsy? Select all that apply a) spasticity b) xeropthalmia c) tremors d) loss of coordination/balance e) moon face f) tooth erosion g) butterfly rash

a) spasticity c) tremors d) loss of coordination/balance

* A nurse is collecting data from an infant who has hypertrophic pyloric stenosis. Which of the following findings should the nurse expect? a. Projectile vomiting b. Bile-colored vomit c. Absent bowel sounds d. Fever

a. Projectile vomiting Rationale:Pyloric stenosis is a narrowing of the pylorus, the outlet from the stomach to the small intestine,which does not allow for emptying of the stomach contents. Vomiting, which is usually mild at first, becomes more forceful and progresses to projectile vomiting.

A nurse is assessing a school age child whose blood glucose is 280. which of the following findings should be expected? a. lethargy b. pallor c. tremor d. shallow respirations

a. lethargy A blood glucose of 280 mg/dL is above the expected reference range indicating hyperglycemia. The nurse should expect the child to appear lethargic, leading to a decreased level of consciousness and confusion.

A nurse is performing an initial home visit to an infant born 3 days ago. Which of the following findings should prompt the nurse to speak to the primary care provider who is caring for the mother and infant? a. The infant is breastfeeding every 2 to 4 hours for approximately 25 minutes on each breast. b. The infant is stooling after every feed and the stool is yellowish-green in color. c. The infant's anterior fontanel is bulging. d. The infant occasionally spits up a small amount of breast milk after feedings. e. The infant cries when hungry and stops when offered the breast.

c. The infant's anterior fontanel is bulging. The physician should be notified immediately if the infant's fontanels are bulging (which could indicate a serious condition such as meningitis) or sunken (which could indicate dehydration).

1. A nurse is caring for a client who has an unrepaired femur fracture of the midshaft. Which of the following techniques should the nurse use when performing an assessment of the client's neurovascular status? a. Measure the circumference of the thigh b. Monitor the client's calf for edema Palpate the femoral pulse c. instruct the client to wiggle his toes d. palpate the femoral

c. instruct the client to wiggle his toes

A nurse is teaching a school-age child who has type 1 diabetes mellitus and his parents about illness management. Which of the following instructions should the nurse include? a. withhold insulin dose if feeling nauseous b. notify the provider if blood glucose levels are over 350 c. test the urine for ketones d. limit fluid intake during meal time

c. test the urine for ketones The parent or child should test the urine for ketones and report the presence of them in the urine. Ketonuria can indicate that the child does not have enough glucose for energy and is breaking down fats to provide glucose to cells. The nurse should instruct the school-age child and his parent to notify the provider if his blood glucose levels are greater than 250 mg/dL in order to initiate treatment before injury can occur.

A nurse is collecting data from an infant who has acute gastroenteritis. Which of the following findings should the nurse identify as a manifestation of severe dehydration? A. Weight loss of 5% B. Mild irritability C. Capillary refill of 3 seconds D. Skin that is cool to the touch

D. Skin that is cool to the touch