PN Nursing Care of Children Online Practice 2020 A with NGN

A nurse is caring for a school-age child who has been admitted to the facility in sickle cell crisis. The nurse is measuring the child's oral intake for the shift. The child consumed 4 oz of juice at breakfast. For lunch, the child consumed 6 oz of milk, 6 oz of gelatin, and drank 7 oz of water. What is the child's oral intake for this shift in milliliters? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.)

690 mL

The nurse is reinforcing teaching about the epinephrine auto-injector prior to discharge. Which of the following statements by the child's family indicates an understanding of the teaching? Select all that apply.

"I will inject this medicine into my child's belly" is incorrect. The injection should be administered into the child's thigh. "I need to press the auto-injector firmly against the skin" is correct. The auto-injector should be held firmly against the skin to initiate the auto-injector function and to enable delivery of the medication into the muscle. "I should hold the auto-injector in place for 30 seconds" is incorrect. Depending on the manufacturer, recommended times can vary from 2 to 10 seconds. Holding the auto-injector in place for longer than the recommended time can result in injury. "I should take my child to the hospital after using an auto-injector, even if they feel better" is correct. The child should be evaluated by a health care provider after experiencing manifestations of anaphylaxis. "I can administer this shot through clothing" is correct. The auto-injector is designed to administer medication through clothing, if necessary, to provide for privacy and facilitate rapid administration.

A nurse in an outpatient clinic is assisting in the care of a 10-year-old child. For each finding, click to specify if the finding is consistent with a tick bite, bee or wasp sting, or brown recluse spider bite. Each finding may support more than one disease process.

-Puncture site is consistent with a bee or wasp sting and a brown recluse spider bite. A visible puncture site could be caused by the stinger of a bee or wasp, or the fang of a brown recluse spider. In the case of a tick bite, a puncture site would not be visible because the head of the tick remains embedded into the skin. -Generalized edema of the foot is consistent with a bee or wasp sting. Tick bites can cause localized edema, rather than generalized edema. Brown recluse spider bites present with a blister, rather than generalized edema. -Erythema is consistent with a bee or wasp sting and a brown recluse spider bite. A tick bite can cause erythema migrans, but not until 3 to 30 days after the initial bite. -Pruritis is consistent with a tick bite, a bee or wasp sting, and a brown recluse spider bite. In the case of a tick bite, pruritis can be caused by the tick's saliva and feces when the tick is embedded in the skin. For bee or wasp stings and brown recluse spider bites, pruritis can be caused by a reaction to the venom. -Pain is consistent with a bee or wasp sting and a brown recluse spider bite. Severe pain can be an indication of a systemic reaction to a bee or wasp sting and a brown recluse spider bite can result in severe pain within 2 to 8 hr. In the case of a tick bite, clients do not usually experience pain as a result of the initial bite.

The nurse reviews provider prescriptions and reexamines the child. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the client. Administer a corticosteroid. Administer an antibiotic. Prepare the child for an incision and drainage at the sting site. Administer antivenin. Instruct the family about the use of an epinephrine auto-injector.

Administer antivenin is contraindicated. Antivenin is administered for snake bites, scorpion stings, or black widow spider bites. It should not be administered for a bee or wasp sting. Administer a corticosteroid is anticipated. The nurse should anticipate a provider prescription for a corticosteroid medication. Corticosteroids are used as anti-inflammatory medication to treat allergic reactions, airway edema, and shock. Instruct the family about the use of an epinephrine auto-injector is anticipated. A child who is allergic to insect venom should be prescribed an epinephrine auto-injector and their family should receive instruction on how to use the equipment to prevent anaphylactic reactions caused by stinging insects. Administer an antibiotic is contraindicated. Antibiotics are not necessary in the treatment of bee and wasp stings. However, antibiotics can be used to treat a brown recluse spider bite or Lyme disease, which can be caused by a tick bite. Prepare the child for an incision and drainage at the sting site is contraindicated. The nurse should not anticipate a provider prescription for an incision and drainage because there is no indication that the child has an abscess or any other skin manifestation that requires draining.

A nurse in a community center is reinforcing teaching about poison control with a group of parents. A parent asks what to do if a child ingests a large quantity of acetaminophen. Identify the sequence of acitons the nurse should recommend to the parent.

Determine if the child is breathing is the first step. The child's respiratory and cardiovascular status should be checked first to determine if CPR is necessary. Empty the child's mouth of remaining pills and residue is the second step. The child's mouth should be emptied of pills and residue to prevent additional exposure to the medication. Identify the medication and dosage strength is the third step. The parent should identify the medication and dosage strength by looking at the medication container. Call a poison control center is the fourth step. The parent should contact a poison control center for advice on the next course of action.

A nurse is in an outpatient clinic assisting in the care of a 10 year old child. Click to highlight the findings the nurse should report to the provider. To deselect a finding, click on the finding again. Puncture site visible on left great toe. Entire left foot swollen, erythematous, and warm to touch. Pedal pulses palpate equal and strong. No edema noted above the ankle. Scar noted on left foot 2.5 cm long. Child reports itching "all over" their body. Child rates pain to left foot as 7 on a scale of 0 to 10. Respirations are easy and unlabored. Child is awake, alert, and answering questions appropriately.

Puncture site visible on left great toe. Entire left foot swollen, erythematous, and warm to touch. Pedal pulses palpate equal and strong. No edema noted above the ankle. Scar noted on left foot 2.5 cm long. Child reports itching "all over" their body. Child rates pain to left foot as 7 on a scale of 0 to 10. Respirations are easy and unlabored. Child is awake, alert, and answering questions appropriately. -Puncture site visible on left great toe is correct. A visible puncture site on the left great toe could be the result of an insect bite. The nurse should report this finding to the provider. -Entire left foot swollen, erythematous, and warm to touch is correct. Generalized swelling indicates the presence of a systemic reaction. Therefore, this finding should be reported to the provider. -Pedal pulses palpate equal and strong is incorrect. This is an expected finding and does not need to be reported to the provider. -No edema noted above the ankle is incorrect. This is an expected finding and does not need to be reported to the provider. -Scar noted on left foot 2.5 cm long is incorrect. This is not an acute finding and does not need to be reported to the provider. -Child reports itching "all over" their body is correct. Increased itching can be an indication of a systemic reaction. Therefore, this finding should be reported to the provider. -Child rates pain to left foot as 7 on a scale of 0 to 10 is correct. The child is reporting moderate to severe pain, which is a possible indication of a systemic reaction. Therefore, this finding should be reported to the provider. -Respirations are easy and unlabored is incorrect. This is an expected finding and does not need to be reported to the provider. -Child is awake, alert, and answering questions appropriately is incorrect. This is an expected finding and does not need to be reported to the provider.

A nurse is reinforcing discharge teaching with the guardian of a child who has juvenile idiopathic arthritis (JIA). Which of the following statements by the guardian indicates an understanding of the teaching? a. "I will have my child sleep in knee, wrist, and hand splints." b. "I will encourage my child to take an afternoon nap." c. "I will apply topical hydrocortisone to my child's joints as needed." d. "I will administer opioids to my child for the next several months to control the pain."

a. "I will have my child sleep in knee, wrist, and hand splints." (The nurse should reinforce with the guardian that splinting the child's joints at night will decrease pain and enhance joint function.) -"I will encourage my child to take an afternoon nap." The nurse should reinforce with the guardian that the child should avoid taking naps during the day because this can increase joint stiffness and interfere with nighttime sleeping. -"I will apply topical hydrocortisone to my child's joints as needed." The nurse should reinforce with the guardian that a topical hydrocortisone is not effective in the treatment of JIA. Corticosteroids are administered orally, into the joints, intravenously, or intraocular for the child who has JIA. -"I will administer opioids to my child for the next several months to control the pain." The nurse should reinforce with the guardian that children who have JIA should avoid long-term opioid use.

The nurse reviews provider prescriptions and reexamines the child. Complete the following sentence by using the lists of options. The nurse should first _______ followed by ______.

The nurse should first apply oxygen followed by assist with establishing IV access. Dropdown 1 Apply oxygen is correct. Using the airway, breathing, circulation approach to client care, the nurse should identify that the priority action is to apply oxygen. The child's increased respiratory rate and decreased oxygen saturation are indications of respiratory distress and should be addressed immediately. Administer PO diphenhydramine is incorrect. The child should receive an antihistamine to treat the allergic reaction. However, there is another action the nurse should take first. Place an intubation tray at the bedside is incorrect. The nurse should place an intubation tray at the bedside if the child begins displaying manifestations of anaphylaxis. However, there is another action the nurse should take first. Dropdown 2 Assist with establishing IV access is correct. Using the airway, breathing, circulation approach to client care, the next action the nurse should take is to assist with establishing IV access in the event rapid administration of medications and fluids becomes necessary. Request a prescription for an antiemetic is incorrect. The nurse might need to request a prescription to treat the child's nausea. However, there is another action the nurse should take first. Apply cool compresses to the trunk is incorrect. The nurse should apply cool compresses to the hives to increase the child's comfort. However, there is another action the nurse should take first.

The nurse is preparing to administer epinephrine. Which of the following actions should the nurse plan to take? Select the 4 actions the nurse should plan to take when administering the epinephrine.

Verify the dosage with another nurse is correct. The nurse should verify the correct dosage with another nurse because epinephrine is a high-alert medication that has an increased risk for significant adverse effects. Administer the medication in the anterolateral thigh is correct. The nurse should administer the medication in the anterolateral thigh because this is the preferred site to enhance the effectiveness of the medication. Administering in any other large muscle can cause infection and might not be as effective. Plan to rotate the injection site if additional injections are required is correct. The nurse should plan to rotate the injection site if the child requires additional injections because tissue necrosis is a potential adverse effect of this medication. Massage the injection site after administration is correct. The nurse should massage the injection site after administration because this increases absorption of the medication and reduces vasoconstriction at the site. Monitor for hypotension is incorrect. The nurse should monitor the child for hypertension, rather than hypotension, because epinephrine causes vasoconstriction. Vasoconstriction can cause heart rate and cardiac output to increase, leading to an increase in the child's blood pressure.

A nurse is reinforcing discharge teaching with the parent of a school-age child who is being treated for nephrotic syndrome. The parent asks the nurse why it is necessary to check the child's urine for protein. Which of the following explanations should the nurse offer? a. "A decrease in urine protein indicates that treatment is effective." b. "Protein in the urine indicates your child's protein intake is adequate." c. "Protein in the urine indicates a need to begin dialysis." d. "An increase in urine protein indicates your child has a secondary infection."

a. "A decrease in urine protein indicates that treatment is effective." (The desired outcome of steroid therapy in the treatment of nephrotic syndrome is a reduction of proteinuria.) -"Protein in the urine indicates your child's protein intake is adequate." Protein in the urine indicates abnormal glomerular permeability. However, it does not indicate that the child's protein intake is inadequate. -"Protein in the urine indicates a need to begin dialysis." Protein in the urine indicates abnormal glomerular permeability. However, it does not indicate a need to begin dialysis. -"An increase in urine protein indicates your child has a secondary infection." Protein in the urine indicates abnormal glomerular permeability. However, it does not indicate a secondary infection. The presence of leukocytes in the urine indicates a urinary tract infection.

A nurse is reviewing the laboratory report of a preschooler. Which of the following laboratory results should the nurse report to the provider? a. Potassium 4.2 mEq/L b. Lead 14 mcg/dL c. Fasting blood glucose 75 mg/dL d. Hematocrit 40%

b. Lead 14 mcg/dL (This lead level is above the expected reference range for a preschooler. Therefore, the nurse should report this result to the provider.) -Potassium 4.2 mEq/L This potassium level is within the expected reference range for a preschooler. -Fasting blood glucose 75 mg/dL This glucose level is within the expected reference range for a preschooler. -Hematocrit 40% This hematocrit level is within the expected reference range for a preschooler.

A nurse is caring for a school-age girl who is being treated for frequent, severe urinary tract infections (UTIs). The nurse should recognize that which of the following statements by the parent indicates a possible cause of the UTIs? a. "My daughter has bowel movements every 4 to 5 days." b. "I taught her to wipe from front to back after going to the bathroom." c. "She urinates every 2 to 3 hours during the day." d. "I don't let her wear nylon underwear."

a. "My daughter has bowel movements every 4 to 5 days." (The nurse should recognize that this frequency indicates the child is constipated. Therefore, large stool masses might prevent complete emptying of the bladder and lead to urinary stasis and infection.) -"I taught her to wipe from front to back after going to the bathroom." The nurse should recognize that the child will improve perineal hygiene by wiping from front to back, which decreases the likelihood for a UTI. -"She urinates every 2 to 3 hours during the day." The nurse should recognize that frequent emptying of the bladder prevents urinary stasis and infection. -"I don't let her wear nylon underwear." The child should wear cotton underwear to help prevent UTIs, because nylon underwear is more likely to trap bacteria in the genital area.

A nurse in a pediatric clinic is collecting data from an infant who was recently exposed to pertussis. The nurse should recognize which of the following as a manifestation of pertussis? a. Dry cough b. Abdominal pain c. Muscle stiffness d. Swollen eyelids

a. Dry cough (The nurse should identify that a dry cough is an early manifestation of pertussis.) -Abdominal pain Abdominal pain is a manifestation of scarlet fever, rather than pertussis. -Muscle stiffness Muscle stiffness is a manifestation of poliomyelitis, rather than pertussis. -Swollen eyelids Swollen eyelids are a manifestation of bacterial conjunctivitis, rather than pertussis.

A nurse is caring for a child who has a fractured tibia and is in Buck's traction. Which of the following actions should the nurse take? a. Ensure the weights are hanging freely. b. Allow the child to change positions frequently. c. Use palms of hands when handling the traction boot. d. Check the pin site every 8 hr.

a. Ensure the weights are hanging freely. (The nurse should ensure that the weights are hanging freely for a child who is in Buck's traction.) -Allow the child to change positions frequently. The nurse should keep a child in the center of the bed in supine position when using Buck's traction. -Use palms of hands when handling the traction boot. The nurse should use the palms of their hands when touching a damp, plaster cast, but this is not necessary when handling a boot in Buck's traction. -Check the pin site every 8 hr. Buck's traction is skin traction. The child does not have pin sites to check.

A nurse is collecting data about a 4-year-old preschooler's gross motor skills. The nurse should expect the preschooler to be able to perform which of the following activities? a. Hopping on one foot b. Skipping on alternate feet c. Jumping rope d. Roller skating

a. Hopping on one foot (The nurse should expect to find that a 4-year-old preschooler is able to hop on one foot.) -Skipping on alternate feet The nurse should expect to find that a 5-year-old preschooler is able to skip on alternate feet. -Jumping rope The nurse should expect to find that a 5-year-old preschooler is able to jump rope. -Roller skating The nurse should expect to find that a 5-year-old preschooler is able to roller skate.

A nurse is reviewing the medical record of a female adolescent client who has primary amenorrhea. Which of the following findings should the nurse identify as a risk for this disorder? (Select all) a. Hypothyroidism b. Obesity c. Cannabis use d. Oral contraceptive use e. Emotional stress

a. Hypothyroidism c. Cannabis use d. Oral contraceptive use e. Emotional stress -Hypothyroidism is correct. The nurse should identify that hypothyroidism and other endocrine disorders are risk factors for primary amenorrhea. -Obesity is incorrect. The nurse should identify that anorexia nervosa and strenuous exercise are risk factors for primary amenorrhea. Clients who have low BMIs can experience an increase in prolactin secretions, which can result in amenorrhea. -Cannabis use is correct. The nurse should identify that cannabis use is a risk factor for primary amenorrhea.Oral -contraceptive use is correct. The nurse should identify that oral contraceptive use affects the estrogen and progesterone cycle and is a risk factor for primary amenorrhea. -Emotional stress is correct. The nurse should identify that emotional stress causes hypothalamic suppression and is a risk factor for primary amenorrhea.

A nurse is assisting with the administration of a nasogastric enteral feeding for an infant. Which of the following actions should the nurse take? a. Place the infant in semi-Fowler's position for 1 hr after the feeding. b. Flush the tube with 30 mL of normal saline before the feeding. c. Warm the feeding in the microwave immediately prior to administration. d. Auscultate over the infant's epigastric area to ensure proper tube placement.

a. Place the infant in semi-Fowler's position for 1 hr after the feeding. (The nurse should elevate the head of the infant's bed by 30º to 45º for 30 min to 1 hr after the feeding.) -Flush the tube with 30 mL of normal saline before the feeding. The nurse should not flush the tube prior to the feeding. Additionally, when flushing the tube for medication administration, the nurse should use sterile water, rather than normal saline. -Warm the feeding in the microwave immediately prior to administration. The nurse should administer the feeding solution at room temperature to decrease gastrointestinal discomfort. -Auscultate over the infant's epigastric area to ensure proper tube placement. Auscultating over the infant's epigastric area does not ensure proper tube placement.

A nurse is contributing to the plan of care for a child who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following is the priority intervention for the nurse to recommend to include in the plan? a. Promote oxygen utilization. b. Administer antibiotics. c. Encourage fluid intake. d. Apply a warm compress to the joints.

a. Promote oxygen utilization. (The priority action the nurse should take when using the airway, breathing, circulation (ABC) approach to client care is promoting oxygen utilization to prevent further sickling of the red blood cells and promote adequate oxygenation of the tissue.) -Administer antibiotics. The nurse should administer antibiotics to treat any existing infection. However, there is another priority intervention the nurse should include in the plan of care. -Encourage fluid intake. The nurse should encourage fluid intake to prevent dehydration and clumping of the red blood cells. However, there is another priority intervention the nurse should include in the plan of care. -Apply a warm compress to the joints. The nurse should apply a warm compress to the joints to reduce pain and inflammation. However, there is another priority intervention the nurse should include in the plan of care.

A nurse is caring for a school-age child who has skeletal traction applied to the right lower leg to repair a femur fracture. Which of the following findings is the priority for the nurse to report to the provider? a. Report of tingling in the right foot b. Pain rating of 7 on a scale of 0 to 10 c. Decrease in food intake d. Increase in crusting at pin sites

a. Report of tingling in the right foot (The nurse should identify that the greatest risk to the child is nerve injury. Therefore, tingling in the right foot, which can indicate nerve damage or compartment syndrome, is the priority finding for the nurse to report to the provider.) -Pain rating of 7 on a scale of 0 to 10 The nurse should identify that muscular pain is an expected finding for a child who is in skeletal traction, and a pain rating of 7 on a scale of 0 to 10 is common. The nurse should report this finding to the provider if it is unrelieved by prescribed analgesics. However, another finding is the priority for the nurse to report to the provider. -Decrease in food intake The nurse should identify that a decrease in food intake is due to a decrease in appetite. This is an expected finding for a child who is in skeletal traction due to pain and immobility. The nurse should report inadequate nutritional intake to the provider. However, another finding is the priority for the nurse to report to the provider. -Increase in crusting at pin sites The nurse should identify that increased crusting at pin sites can possibly indicate infection and should be reported to the provider and monitored closely. However, another finding is the priority for the nurse to report to the provider.

A nurse is contributing to the plan of care for a school-age child who has acute poststreptoccal glomerulonephritis (APSGN) and is mildly hypertensive. Which of the following actions should the nurse include in the plan of care? a. Restrict the child's sodium intake. b. Weigh the child every other day. c. Monitor the child's blood pressure every 12 hr. d. Place the child on bed rest.

a. Restrict the child's sodium intake. (The nurse should limit the sodium intake for a child who has APSGN and is hypertensive or who has a decreased urine output to help prevent water retention and edema.) -Weigh the child every other day. The nurse should weigh a child who has APSGN every day to monitor fluid balance. -Monitor the child's blood pressure every 12 hr. The nurse should monitor the blood pressure of a child who has APSGN every 4 to 6 hr. -Place the child on bed rest. The nurse should identify that ambulation does not negatively affect a child who has mild hypertension associated with APSGN.

A nurse is auscultating heart sounds on an infant. The nurse should identify this sound as which of the following? a. Sinus rhythm b. Ventricular septal defect c. Pulmonic stenosis d. Atrial septal defect

a. Sinus rhythm (The nurse should identify this heart sound as sinus rhythm. The nurse should auscultate heart sounds at the apical impulse, which is at the left midclavicular line and fifth intercostal space. The expected heart sounds include S1, which is the closure of the atrioventricular valves, and S2, which is the closure of the semilunar valves.) -Ventricular septal defect The nurse should identify that an infant who has a ventricular septal defect will exhibit a characteristic murmur. -Pulmonic stenosis The nurse should identify that an infant who has a pulmonic stenosis will exhibit a characteristic murmur. -Atrial septal defect The nurse should identify that an infant who has an atrial septal defect will exhibit a characteristic murmur.

A nurse is reinforcing teaching with the parents of a 7-year-old female child about behavioral expectations. Which of the following behaviors should the nurse include in the teaching? a. Spends a lot of time by herself b. Exhibits a decline in self-esteem c. Selectively chooses a best friend d. Shows a competitive nature with others

a. Spends a lot of time by herself (Spending time alone is an expected characteristic of a 7-year-old female child. When they do spend time with others, children in this age group prefer to socialize with children of the same sex and age.) -Exhibits a decline in self-esteem Children who are 11 to 14 years of age exhibit a decline in self-esteem because they measure social status by acceptance or rejection by peers. -Selectively chooses a best friend Children who are 10 to 12 years of age are expected to be selective in their choices of friends and typically have a best friend. -Shows a competitive nature with others Children who are 8 to 9 years of age are expected to be competitive with others.

A nurse is reinforcing dietary teaching with the guardian of a school-age child who has celiac disease. Which of the following foods should the nurse recommend including in the child's diet? a. White rice b. Whole wheat bread c. Graham crackers d. French fries

a. White rice (The nurse should reinforce to the guardian that celiac disease is a genetic autoimmune disorder in which eating gluten, even in very small amounts, can damage the child's small intestine. Currently, the only treatment for the disease is a lifelong, strict adherence to a gluten-free diet. The nurse should stress the importance of avoiding foods containing wheat, rye, barley, and oats. The child should consume foods that are gluten-free, such as milk, cheese, rice, corn, eggs, potatoes, fruits, vegetables, fresh poultry, meats, fish, and dried beans.) -Whole wheat bread Wheat contains gluten, and treatment for celiac disease is limited to avoiding gluten. -Graham crackers Graham crackers contain gluten, and treatment for celiac disease is limited to avoiding gluten. -French fries French fries contain gluten, and treatment for celiac disease is limited to avoiding gluten.

A nurse is reinforcing teaching about home safety with the parent of a toddler. Which of the following parent statements indicated an understanding of the teaching? a. "I will keep my hearing aid batteries in my bedside table." b. "I will place a screen in front of the fireplace." c. "I will keep my medication in my purse." d. "I will use a steam vaporizer when my child has a cold."

b. "I will place a screen in front of the fireplace." (The nurse should instruct the parent to place a screen in front of a fireplace or other heating appliances to prevent burns.) -"I will keep my hearing aid batteries in my bedside table." The nurse should instruct the parent to place all batteries in an elevated and secure location to prevent injury. -"I will keep my medication in my purse." The nurse should instruct the parent to keep all medications in a locked medicine cabinet or high shelf that is not accessible to the child to prevent accidental poisoning. -"I will use a steam vaporizer when my child has a cold." The nurse should instruct the parent to use a cool mist, instead of a steam vaporizer, to prevent injury from burns.

A nurse is reinforcing teaching with an adolescent female client who has acne vulgaria and a new prescription for isotretinoin. Which of the following information should the nurse include? a. "You should apply this medication to the affected skin twice daily." b. "You will need to have two negative pregnancy tests prior to starting this medication." c. "Your provider will monitor your kidney function while you are taking this medication." d. "Your provider will prescribe a vitamin A supplement to take with each dose of this medication."

b. "You will need to have two negative pregnancy tests prior to starting this medication." (The nurse should reinforce with the client that isotretinoin is teratogenic. Pregnancy must be ruled out prior to administration and before each subsequent refill. The client should use two effective forms of contraception while taking this medication.) -"You should apply this medication to the affected skin twice daily." The nurse should reinforce with the client that isotretinoin is administered PO. -"Your provider will monitor your kidney function while you are taking this medication." The nurse should reinforce with the client that she will need regular monitoring of liver function and glycemic control while taking isotretinoin. -"Your provider will prescribe a vitamin A supplement to take with each dose of this medication." The nurse should reinforce with the client that she should avoid vitamin A supplements while taking isotretinoin because of the increased risk for adverse effects and medication toxicity.

A nurse is assisting with a sterile dressing change for an adolescent who has a partial thickness burn on the right hip. Which of the following actions should the nurse take first? a. Open the sterile dressing tray. b. Administer pain medication to the client. c. Assist the client into the left lateral position. d. Remove the previous dressing to inspect the wound.

b. Administer pain medication to the client. (According to evidence-based practice, the nurse should first provide pain medication to the client to reduce discomfort during the procedure.) -Open the sterile dressing tray. The nurse should open the sterile dressing tray prior to cleansing the wound. However, there is another action the nurse should take first. -Assist the client into the left lateral position. The nurse should assist the client into the left lateral position before removing the soiled dressing. However, there is another action the nurse should take first. -Remove the previous dressing to inspect the wound. The nurse should remove the previous dressing and inspect the wound to identify infection. However, there is another action the nurse should take first.

A nurse is reinforcing dietary teaching about a low-sodium diet with the parents of a child who is recovering from acute glomerulonephritis. Which of the following food choices by the parents indicates an understanding of the teaching? a. Pretzels b. Apples c. Canned corn d. Peanut butter

b. Apples (The nurse should instruct the parents that apples are low in sodium and supply the child with energy needed for recovery.) -Pretzels Sodium should be restricted for a child who is recovering from acute glomerulonephritis, and pretzels are high in sodium. -Canned corn Sodium should be restricted for a child who is recovering from acute glomerulonephritis, and canned vegetables, such as canned corn, are high in sodium. -Peanut butter Sodium should be restricted for a child who is recovering from acute glomerulonephritis, and peanut butter is high in sodium.

A nurse is preparing to administer ophthalmic drops to a child. Which of the following actions should the nurse take? a. Position the child with his head flexed while administering the medication. b. Apply pressure to the lacrimal punctum for 1 min following administration. c. Hold the dropper 5 cm (2 in) above the eye to administer the medication. d. Wipe the excess medication toward the inner canthus with a cotton swab.

b. Apply pressure to the lacrimal punctum for 1 min following administration. (The nurse should apply pressure to the lacrimal punctum to prevent the medication from entering the nasopharynx.) -Position the child with his head flexed while administering the medication. The nurse should have the child extend his head while administering the ophthalmic drops. -Hold the dropper 5 cm (2 in) above the eye to administer the medication. The nurse should hold the dropper 1 to 2 cm (0.4 to 0.8 in) above the eye to administer the medication. -Wipe the excess medication toward the inner canthus with a cotton swab. The nurse should wipe the excess medication from the inner canthus outward.

A nurse is assisting with scoliosis screenings for a group of school-age children. The nurse should place the students in which of the following positions during the screening? a. Clasping hands while arms are raised above the head b. Bending forward with back parallel to the floor c. Standing with feet shoulder-width apart d. Bending knees while placing hands on hips

b. Bending forward with back parallel to the floor (The nurse should observe for asymmetry and prominence of the rib cage by having the students bend forward with the back parallel to the floor.) -Clasping hands while arms are raised above the head Clasping hands while arms are raised above the head can cause an asymmetrical appearance and result in inaccurate screening results. -Standing with feet shoulder-width apart Standing with the feet shoulder-width apart can cause an asymmetrical appearance and result in inaccurate screening results. -Bending knees while placing hands on hips Bending the knees while placing the hands on the hips can cause an asymmetrical appearance and result in inaccurate screening results.

A nurse is collecting data from a child who has iron deficiency anemia. Which of the following data signifies that adherence to ferrous sulfate therapy has occurred? a. Occasional vomiting and nausea b. Green, tarry stools c. Tolerates milk d. Weight gain

b. Green, tarry stools (Green, tarry stools are an expected outcome of ferrous sulfate therapy. Therefore, this is an indication of adherence to the prescribed medication regimen.) -Occasional vomiting and nausea Occasional vomiting and nausea are adverse effects of ferrous sulfate. -Tolerates milk The ability to tolerate milk does not indicate compliance with ferrous sulfate therapy. -Weight gain Weight gain does not indicate compliance with ferrous sulfate therapy.

A nurse is caring for a child who has a head injury following a motor vehicle crash. Which of the following should the nurse recognize as an early manifestation of increased intracranial pressure? a. Fixed and dilated pupils b. Increased irritability c. Decorticate posturing d. Cheyne-Stokes respirations

b. Increased irritability (The nurse should recognize that increased irritability, fatigue, vomiting, and headache are early signs of increased intracranial pressure.) -Fixed and dilated pupils The nurse should recognize that fixed and dilated pupils are a late sign of increased intracranial pressure. -Decorticate posturing The nurse should recognize that decorticate posturing is a late sign of increased intracranial pressure. -Cheyne-Stokes respirations The nurse should recognize that Cheyne-Stokes respirations are a late sign of increased intracranial pressure.

A nurse is collecting data from an adolescent who has manifestations of physical abuse. Which of the following actions should the nurse take? a. Conduct the admission process with the adolescent's parent at bedside. b. Report the suspected abuse to the authorities. c. Use closed-ended questioning when speaking with the adolescent. d. Encourage the adolescent to enroll in family psychotherapy.

b. Report the suspected abuse to the authorities. (Nurses are required mandatory reporters of child abuse. It is the nurse's responsibility to report any type of abuse to the appropriate agencies. This action will assist with ensuring a safe environment for the adolescent.) -Conduct the admission process with the adolescent's parent at bedside. The nurse should question the adolescent and parent about the suspected abuse separately. -Use closed-ended questioning when speaking with the adolescent. The nurse should use open-ended questioning to obtain the necessary subjective findings. Closed-ended questioning impedes data collection. -Encourage the adolescent to enroll in family psychotherapy. Family psychotherapy should only take place if the perpetrator has attended individual psychotherapy and all parties agree to group therapy.

A nurse is reviewing the laboratory report of a school-age child who is receiving prednisone. Which of the following laboratory results should the nurse report to the provider? a. Fasting blood glucose 74 mg/dL b. Sodium 150 mEq/L c. Potassium 4.2 mEq/L d. WBC count 9,400/mm3

b. Sodium 150 mEq/L (Hypernatremia is an adverse effect of prednisone. This level is above the expected reference range for a school-age child. Therefore, the nurse should report this value to the provider.) -Fasting blood glucose 74 mg/dL Hyperglycemia is an adverse effect of prednisone. However, this level is within the expected reference range for a school-age child. -Potassium 4.2 mEq/L Hypokalemia is an adverse effect of prednisone. However, this level is within the expected reference range for a school-age child. -WBC count 9,400/mm3 A decrease in WBC count is an adverse effect of prednisone. However, this WBC count is within the expected reference range for a school-age child.

A nurse assisting the provider with a developmental assessment of a toddler. Which of the following behaviors should the nurse recognize as an expected finding? a. Walks backward with heel to toe b. Stands on one foot for several seconds c. Uses scissors to cut out shapes d. Prints letters with a pencil

b. Stands on one foot for several seconds (Standing on one foot for several seconds is an expected behavior for a toddler.) -Walks backward with heel to toe Walking backward with heel to toe is an expected behavior for a 5-year-old child. -Uses scissors to cut out shapes Using scissors to cut out shapes is an expected behavior for a 4-year-old child. -Prints letters with a pencil Printing letters with a pencil is an expected behavior for a 5-year-old child.

A nurse is reinforcing teaching with the guardian of a child who has a new diagnosis of enterobiasis. The nurse should advise the guardian to take which of the following actions to prevent infection? a. Dress the child in two-piece sleeping outfits. b. Trim the child's fingernails short. c. Have the child take a tub bath daily. d. Repeat treatment in 4 weeks.

b. Trim the child's fingernails short. (The nurse should instruct the guardian to trim the child's fingernails short to reduce the collection of eggs under their nails and prevent reinfection.) -Dress the child in two-piece sleeping outfits. The nurse should instruct the guardian to have the child wear one-piece sleeping outfits to minimize scratching of the perianal area. -Have the child take a tub bath daily. The nurse should instruct the guardian to have the child take showers, instead of tub baths, because tub baths can increase the incidence of reinfection. -Repeat treatment in 4 weeks. The nurse should instruct the guardian that treatment with antiparasitic medication should be repeated in 2 weeks to prevent reinfection.

A nurse is reinforcing teaching about glucose monitoring with the parent of a child who has type 1 diabetes mellitus. Which of the following instructions should the nurse include in the teaching? a. "Press the platform of the lancet firmly against your child's finger." b. "Obtain the blood sample from the center of your child's finger pad." c. "Put your child's finger under warm, running water prior to collecting blood." d. "Steady the finger against a hard surface while puncturing the skin."

c. "Put your child's finger under warm, running water prior to collecting blood." (The nurse should instruct the parent that placing the child's finger under warm, running water increases the blood flow to the finger, which will make it easier to obtain the sample.) -"Press the platform of the lancet firmly against your child's finger." The nurse should instruct the parent to press lightly against the child's finger with the platform of the lancet to avoid a deep puncture. -"Obtain the blood sample from the center of your child's finger pad." The nurse should instruct the parent to obtain the blood sample from the side of the child's finger pad, because this location has more blood vessels and fewer nerve endings. -"Steady the finger against a hard surface while puncturing the skin." The nurse should instruct the parent to avoid steadying the finger against a hard surface while puncturing the skin to avoid a deep puncture.

A nurse is reinforcing home safety instructions with the parents of a toddler. Which of the following parent statements indicates an understanding of the teaching? a. "We will keep our child out of the sun between 3 p.m. and 5 p.m." b. "We will transition our child to a toddler bed when he is 2 feet tall." c. "We will purchase a toy storage box with a lightweight lid." d. "We will provide a healthy snack of peanuts."

c. "We will purchase a toy storage box with a lightweight lid." (The nurse should instruct the parents to avoid toy boxes with heavy, hinged lids. Toddlers may suffocate or have the lid close on their head or neck, causing injury.) -"We will keep our child out of the sun between 3 p.m. and 5 p.m." The nurse should instruct the parents to keep the toddler out of direct sun exposure between 1000 and 1400 when the sun's rays are strongest. -"We will transition our child to a toddler bed when he is 2 feet tall." The nurse should instruct the parents to keep the toddler in a crib until they have reached a height of 89 cm (35 in). -"We will provide a healthy snack of peanuts." The nurse should instruct the parents to avoid providing snacks, such as peanuts or other hard foods, that can increase the risk for aspiration.

A nurse has just received change-of-shift for four children in a pediatric unit. Which of the following children should the nurse collect data from the first? a. A child who is 2 days postoperative following an appendectomy and reports incisional pain b. A child who has a new diagnosis of diabetes mellitus and an HbA1c level of 7.5% c. A child who has a fever and nuchal rigidity d. A child who experienced a seizure 1 hr ago and is resting

c. A child who has a fever and nuchal rigidity (A child who has a fever and nuchal rigidity is unstable. This finding indicates bacterial meningitis, which requires urgent data collection and intervention to reduce complications for the child and prevent further spread of the infection. Therefore, the nurse should collect data from this child first.) -A child who is 2 days postoperative following an appendectomy and reports incisional pain A child who is 2 days postoperative following an appendectomy and reports incisional pain is stable. Therefore, there is another child the nurse should collect data from first. -A child who has a new diagnosis of diabetes mellitus and an HbA1c level of 7.5% A child who has a new diagnosis of diabetes mellitus and an HbA1c level of 7.5% is stable. Therefore, there is another child the nurse should collect data from first. -A child who experienced a seizure 1 hr ago and is resting A child who experienced a seizure 1 hr ago and is resting is stable. Therefore, there is another child the nurse should collect data from first.

A nurse is collecting data from a 12-month old infant during a well-child visit. Which of the following findings should the nurse report to the provider? a. Heart rate 130/min b. Respiratory rate 30/min c. BP 115/70 mm Hg d. Temperature 37.5° C (99.5° F)

c. BP 115/70 mm Hg (The nurse should identify that this blood pressure is above the expected reference range for a 12-month-old infant and report this finding to the provider.) -Heart rate 130/min This heart rate is within the expected reference range for a 12-month-old infant. -Respiratory rate 30/min This respiratory rate is within the expected reference range for a 12-month-old infant. -Temperature 37.5° C (99.5° F) This temperature is within the expected reference range for a 12-month-old infant.

A nurse is collecting data from a 12-month-old infant during a well-child visit. The nurse should identify which of the following findings as a deviation from expected growth and development? a. Vocabulary of three words b. Negative Babinski reflex c. Birth weight doubled d. Unable to build a two-block tower

c. Birth weight doubled (The nurse should identify this finding as a deviation from expected growth and development. The infant's birth weight should triple by 12 months of age. Therefore, the nurse should report this finding to the provider.) -Vocabulary of three words The nurse should identify a vocabulary of three to five words as an expected finding for a 12-month-old infant. -Negative Babinski reflex The Babinski reflex disappears approximately at the age of 12 months. Therefore, the nurse should identify this as an expected finding. -Unable to build a two-block tower The nurse should identify that attempting, but failing, to build a two-block tower is an expected finding for a 12-month-old infant.

A nurse is preparing to administer an enteral feeding to a child who has cerebral palsy and a nasogastric tube. Which of the following actions should the nurse take? a. Administer 20 mL/min of formula by gravity. b. Refrigerate the formula for 30 min prior to administration. c. Confirm that the pH of the stomach contents is 5 or less. d. Flush the tube with 5 to 15 mL of 0.9% sodium chloride.

c. Confirm that the pH of the stomach contents is 5 or less. (The nurse should test the pH of the stomach contents prior to administering the tube feeding in order to confirm tube placement in the stomach. The nurse should identify that a pH of 5 or less indicates gastric placement.) -Administer 20 mL/min of formula by gravity. The nurse should not exceed 5 mL every 5 to 10 min in premature or infants who are small for gestational age and 10 mL/min in older infants and children. A feeding should take 15 to 30 min to complete to prevent nausea and regurgitation. -Refrigerate the formula for 30 min prior to administration. The nurse should ensure that the formula is at room temperature prior to feeding to avoid abdominal cramping. -Flush the tube with 5 to 15 mL of 0.9% sodium chloride. The nurse should flush the tube with 1 to 15 mL of sterile water to maintain patency.

A nurse in reinforcing teaching with the parents of a toddler who has strabismus. Which of the following treatments should the nurse plan to include in the teaching? a. Corrective biconcave lenses b. Laser surgery c. Eye patch d. Artificial tears

c. Eye patch (Treatment of strabismus includes covering the strong eye to strengthen the muscles in the weak eye.) -Corrective biconcave lenses Corrective biconcave lenses are not prescribed to treat strabismus. Biconcave lenses are used to correct myopia. -Laser surgery Laser surgery is not indicated for strabismus. Strabismus surgery is performed to improve visual stimulation to the weak eye. -Artificial tears Artificial tears are not prescribed to treat strabismus, because dry eyes are not a manifestation of strabismus.

A nurse is assisting with the care of a child who has tonic-clonic seizures. Which of the following actions should the nurse take? a. Ensure the availability of soft extremity restraints. b. Place a padded tongue blade at the bedside. c. Have a suction canister and tubing available in the room. d. Keep the child's bed in the highest position.

c. Have a suction canister and tubing available in the room. (The nurse should have a suction canister and tubing available in the child's room to keep the child's airway patent during a seizure.) -Ensure the availability of soft extremity restraints. The nurse should not ensure the availability of soft extremity restraints, because restraining the child during a seizure can cause injury. -Place a padded tongue blade at the bedside. The nurse should not place a padded tongue blade at the bedside, because placing an object between the child's teeth during a seizure can cause loose or broken teeth. -Keep the child's bed in the highest position. The nurse should keep the child's bed in the lowest position to reduce the risk of injury should the child fall out of bed during a seizure.

A nurse in a pediatric clinic is observing for an anaphylactic reaction after administering an IM antibiotic to a child 5 min ago. Which of the following manisfestations should the nurse expect to observe first? a. Wheezing b. Angioedema c. Hives d. Hypotension

c. Hives (The nurse should observe for hives first because this is an early manifestation of an anaphylactic reaction.) -Wheezing Wheezing is a later manifestation of an anaphylactic reaction. -Angioedema Angioedema is a later manifestation of an anaphylactic reaction. -Hypotension Hypotension is a later manifestation of an anaphylactic reaction.

A nurse is collecting data about the dietary habits of an adolescent female client. The nurse should identify that which of the following findings puts the client at risk for nutritional deficits? a. The client chooses to eat more vegetables than fruits. b. The client consumes approximately 2,000 calories a day. c. The client fasts twice a week to manage dietary intake. d. The client increases their dietary intake during track season.

c. The client fasts twice a week to manage dietary intake. (The nurse should identify that adolescents are often at risk for developing poor eating habits. Regular fasting puts this client at risk for nutritional deficits.) -The client chooses to eat more vegetables than fruits. The client should consume more vegetables than fruits, because fruits are high in sugar content. -The client consumes approximately 2,000 calories a day. Moderately active adolescent females require about 2,000 calories a day. -The client increases their dietary intake during track season. Adolescents should increase their dietary intake to meet increased energy needs when playing sports.

A nurse is monitoring a preschooler following an abdominal CT scan with contrast dye. The nurse should identify which of the following as an indication that the preschooler experienced an allergic reaction to the contrast dye? a. Jaundice b. Hematuria c. Urticaria d. Petechiae

c. Urticaria (The nurse should monitor the child for an allergic reaction to the contrast dye. Manifestations of the allergic reaction include urticaria, itching, flushing of the skin, and possible anaphylaxis.) -Jaundice The nurse should recognize that a child who is experiencing an allergic reaction to contrast dye can have flushed skin or, in the case of respiratory distress, a cyanotic appearance. -Hematuria The nurse should recognize that hematuria is not an expected manifestation of an allergic reaction to contrast dye. Due to a decrease in blood pressure, the child might have oliguria in the event of anaphylactic shock. -Petechiae The nurse should recognize that petechiae is not an expected manifestation of an allergic reaction to contrast dye. Petechiae are areas of ruptured capillaries on the skin that appear as reddish dots or small, red, webbed areas.

A nurse is reinforcing teaching with the guardian of an infant who has Down syndrome. Which of the following instructions should the nurse include to decrease the child's risk of an upper respiratory infection? a. Rinse the infant's mouth with water before feeding. b. Limit the infant's fluid intake. c. Use a cool mist vaporizer in the infant's room. d. Avoid applying lip balm to the infant's lips.

c. Use a cool mist vaporizer in the infant's room. (The nurse should reinforce that a cool mist vaporizer should be used to help thin respiratory secretions and decrease the infant's risk for an upper respiratory infection.) -Rinse the infant's mouth with water before feeding. The nurse should reinforce with the guardian that rinsing the mouth with water after feeding will clear the mouth of residual food, thereby decreasing the infant's risk for an upper respiratory infection. -Limit the infant's fluid intake. The nurse should reinforce that the infant's fluid intake should be increased to thin respiratory secretions and decrease the infant's risk for an upper respiratory infection. -Avoid applying lip balm to the infant's lips. The nurse should reinforce that the infant is at increased risk of excessive drying and chapping of the lips; therefore, the guardian should be encouraged to apply lip balm to the infant, especially if the infant is going to spend time outside.

A nurse is reinforcing teaching with the family of a preschooler whose parent has a terminal diagnosis. Which of the following statements should the nurse include when discussing age-appropriate responses to death? a. "Your child will likely exhibit fear of the impending death with verbal uncooperativeness." b. "At this age, your child will understand that death is irreversible." c. "Your child will likely be curious about what happens to the body after death." d. "At this age, your child likely believes his thoughts can cause another person's death."

d. "At this age, your child likely believes his thoughts can cause another person's death." (The nurse should reinforce that, at this age, the preschooler might believe that his thoughts can cause another person's death, which can make him feel guilty or responsible for the death.) -"Your child will likely exhibit fear of the impending death with verbal uncooperativeness." Exhibiting fear of a parent's impending death with verbal uncooperativeness is an age-appropriate response to death for a school-age child. The preschooler might exhibit regression or use inappropriate behaviors, such as giggling or joking, to cope with the impending loss. -"At this age, your child will understand that death is irreversible." Understanding that death is irreversible will not occur until the child is approximately 9 to 10 years old. The preschooler might believe that death is a sleep-like state that is temporary and gradual. -"Your child will likely be curious about what happens to the body after death." Curiosity about what happens to the body after death is an age-appropriate response to death for a school-age child.

A nurse is monitoring a child who is receiving a transfusion of packed RBCs. Which of the following responses by the child is an indication of a transfusion reaction? a. "My nose is runny. Can I have a tissue?" b. "I am hungry. Can I get a snack?" c. "I am sleepy. I might take a nap after this." d. "I am cold. Can I have an extra blanket?"

d. "I am cold. Can I have an extra blanket?" (The nurse should identify that being cold and having chills is an indication of a transfusion reaction.) -"My nose is runny. Can I have a tissue?" The nurse should identify that a runny nose is not an indication of a transfusion reaction. -"I am hungry. Can I get a snack?" The nurse should identify that being hungry is not an indication of a transfusion reaction. -"I am sleepy. I might take a nap after this." The nurse should identify that sleepiness is not an indication of a transfusion reaction.

A nurse is reviewing the laboratory report of a preschooler who has a Wilms' tumor and is scheduled to begin treatment with an antineoplastic medication regimen. Which of the following laboratory results should the nurse report to the provider? a. BUN 16 mg/dL b. WBC count 5,500/mm3 c. Serum glucose 98 mg/dL d. Platelet count 70,000/mm3

d. Platelet count 70,000/mm3 (This platelet count is below the expected reference range for a preschooler and increases the risk for spontaneous bleeding. The nurse should hold the medication and report this finding to the provider immediately.) -BUN 16 mg/dL This BUN level is within the expected reference range for a preschooler. -WBC count 5,500/mm3 This WBC count is within the expected reference range for a preschooler. -Serum glucose 98 mg/dL This serum glucose level is within the expected reference range for a preschooler.

A nurse is reinforcing discharge teaching with the guardian of a school-age child who has a new prescription for home oxygen therapy. Which of the following statements by the guardian indicates an understanding of the teaching? a. "I will restrict the length of the oxygen tubing to no longer than 3 feet." b. "I will place the extra oxygen tanks in a horizontal position for storage." c. "I will check the oxygen delivery equipment once every week." d. "I will make sure that electrical devices in the house are grounded."

d. "I will make sure that electrical devices in the house are grounded." (This response by the guardian indicates an understanding of the nurse's instructions. Due to the combustible nature of oxygen, all pieces of electrical equipment in the home should be grounded to decrease the risk of a fire caused by an electrical spark.) -"I will restrict the length of the oxygen tubing to no longer than 3 feet." The guardian should ensure that the length of the oxygen tubing is sufficient to allow the child to move easily within the home environment. Oxygen can be delivered effectively through tubing of a length up to 30 m (98 feet). -"I will place the extra oxygen tanks in a horizontal position for storage." Oxygen tanks should be stored vertically, not horizontally. Placing a full oxygen tank on its side can cause the tank to rupture, which can lead to serious injuries of individuals in the home. -"I will check the oxygen delivery equipment once every week." The guardian should check the child's oxygen equipment and oxygen delivery at least once each day.

A nurse is caring for an adolescent client who is a practicing Jehovah's Witness and is scheduled for surgery for a ruptured appendix. The adolescent tells the nurse that based on their religious beliefs, they cannot receive a blood transfusion. Which of the following responses should the nurse make? a. "Why do members of your faith believe this?" b. "You'll only receive blood during the procedure if you need it." c. "I will let the surgical team know your wishes." d. "Let's discuss the possible need for a transfusion with your parents."

d. "Let's discuss the possible need for a transfusion with your parents." (The nurse should offer to involve the child's parents to understand the family's beliefs about blood transfusions.) -"Why do members of your faith believe this?" The nurse should avoid asking a "why" question, because it can appear judgmental or accusatory. -"You'll only receive blood during the procedure if you need it." The nurse should not use false reassurance because it can belittle the child's feelings and concerns. -"I will let the surgical team know your wishes." The nurse should avoid using automatic responses and instead use therapeutic communication to explore the cultural request.

A nurse is caring for an adolescent client who is experiencing sickle cell crisis. Which of the following laboratory values should the nurse report to the provider? a. Total bilirubin 0.5 mg/dL b. Reticulocyte count 1% c. WBC count 8,000/mm3 d. Hgb 6 g/dL

d. Hgb 6 g/dL (The expected reference range for an adolescent's Hgb level is 10 to 15.5 g/dL. Therefore, an Hgb of 6 g/dL is below the expected reference range and should be reported to the provider.) -Total bilirubin 0.5 mg/dL The expected reference range for an adolescent's total bilirubin is 0.3 to 1.0 mg/dL. Therefore, a total bilirubin of 0.5 mg/dL is within the expected reference range and does not need to be reported to the provider. -Reticulocyte count 1% The expected reference range for an adolescent's reticulocyte count is 0.5% to 2%. Therefore, a reticulocyte count of 1% is within the expected reference range and does not need to be reported to the provider. -WBC count 8,000/mm3 The expected reference range for an adolescent's WBC count is 5,000 to 10,000/mm3. Therefore, a WBC count of 8,000/mm3 is within the expected reference range and does not need to be reported to the provider.

A nurse is contributing to the plan of care for an adolescent who has human immunodeficiency virus (HIV). Based on the adolescent's diagnosis, which of the following actions should be included in the plan of care? a. Instruct visitors to wear gowns and masks when entering the client's room. b. Contact the dietary department to request that foods be delivered on disposable dishes. c. Prepare a negative-pressure airflow room for the client. d. Inform the client regarding routes of transmission.

d. Inform the client regarding routes of transmission. (The nurse should inform the client about the transmission of HIV and how to prevent its spread.) -Instruct visitors to wear gowns and masks when entering the client's room. The nurse should include having visitors wear gowns when entering the room of a client who is on contact precautions when there is a possibility of coming into contact with contaminated objects. The nurse should also include having visitors wear masks when coming within 1 m (3.3 feet) of a client who is on droplet precautions due to an illness that is transmitted through the air via large-particle droplets. -Contact the dietary department to request that foods be delivered on disposable dishes. The nurse should include the use of disposable dishes in the plan of care for a client who is on contact precautions due to an illness that is easily transmitted by direct contact. -Prepare a negative-pressure airflow room for the client. The nurse should include the use of a room with negative-pressure airflow in the plan of care for a client who is on airborne precautions due to an illness that is transmitted through the air via small-particle droplets.

A nurse is collecting data from a toddler at a well-child visit. Which of the following findings should the nurse identify as a possible indication of child maltreatment? a. Diaper dermatitis b. Bruise on the front of the lower leg c. Inflamed unilateral conjunctiva d. Laceration on the side of the torso

d. Laceration on the side of the torso (A laceration on the side of the torso is not an injury that occurs due to the typical clumsiness of a toddler. This finding indicates the need to further investigate for suspected child maltreatment.) -Diaper dermatitis Diaper dermatitis is commonly caused by wearing diapers and does not indicate the need to further investigate for suspected child maltreatment. -Bruise on the front of the lower leg Toddlers are developing gross and fine motor skills and frequently fall, resulting in bruising. A bruise on the front of the lower leg does not indicate the need to further investigate for suspected child maltreatment. -Inflamed unilateral conjunctiva Unilateral inflamed conjunctiva is a manifestation of conjunctivitis caused by a foreign body and does not indicate the need to further investigate for suspected child maltreatment.

A nurse in a clinic is collecting data from an adolescent who has received all recommended immunizations through the age of 6 years. Which of the following immunizations should the nurse paln to administer? a. Haemophilus influenza type b (Hib) b. Rotavirus (RV) c. Polio (IPV) d. Tetanus, diphtheria toxoids, and acellular pertussis (Tdap)

d. Tetanus, diphtheria toxoids, and acellular pertussis (Tdap) (The Tdap vaccine is recommended between the ages of 11 and 12 years. Therefore, this adolescent should receive the Tdap vaccine now.) -Haemophilus influenza type b (Hib) The Hib immunization series is administered by 18 months of age. -Rotavirus (RV) The RV immunization series is administered by 6 months of age. -Polio (IPV) The IPV immunization series is administered by 6 years of age.

A nurse is reinforcing teaching with the guardians of a school-age childwho has hearing loss. Which of the following techniques should the nurse recommend to facilitate communication with the child? a. Exaggerate the pronunciation of each word. b. Keep hands still when speaking. c. Stand away from child when speaking. d. Use facial expressions when speaking.

d. Use facial expressions when speaking. (The nurse should instruct the guardians to use facial expressions when speaking to assist in conveying the message being spoken.) -Exaggerate the pronunciation of each word. The nurse should instruct the guardians to avoid exaggerating the pronunciation of words because this decreases comprehension. -Keep hands still when speaking. The nurse should instruct the guardians to use hand gestures to promote understanding. -Stand away from child when speaking. The nurse should instruct the guardians to stand close to the child and face them directly or at a 45° angle to facilitate communication.