RN Nursing Care of Children Online Practice 2019 A with NGN and rationales

A nurse is auscultating the lungs of an adolescent who has asthma. The nurse should identify the sound as which of the following? Listen to the audio clip Biot respiration Cheyne-Stokes respiration Tachypnea Bradypnea

Biot respiration The nurse should identify Biot respirations as periods of apnea alternating with breaths of increased but consistent depth. Cheyne-Stokes respiration The nurse should identify Cheyne-Stokes respirations as periods of apnea alternating with periods of hyperventilation. CORRECT ANSWER: Tachypnea The nurse should identify the sound heard during auscultation as tachypnea, which is a rapid, regular breathing pattern. This breathing pattern often occurs with anxiety, fever, metabolic acidosis, or severe anemia. Bradypnea The nurse should identify bradypnea as a slow, regular breathing pattern.

A nurse is teaching the parent of an infant who has a Pavlik harness for the treatment of developmental dysplasia of the hip. The nurse should identify that which of the following statements by the parent indicates an understanding of the teaching? "I should remove the harness at night to allow my infant to stretch her legs." "I will need to adjust the straps on the harness once each week." "I should apply baby powder to my infant's skin twice daily." "I will place my infant's diapers under the harness straps."

"I should remove the harness at night to allow my infant to stretch her legs." The harness is to be worn continuously until the hip is stable, which usually occurs within 6 to 12 weeks. Removing the harness frequently or for long periods of time will reduce the effectiveness of the treatment. "I will need to adjust the straps on the harness once each week." The Pavlik harness is designed to maintain the infant's hips in a position of flexion and abduction. The nurse should instruct the parent not to adjust the harness in any way to avoid complications. "I should apply baby powder to my infant's skin twice daily." The use of powders and lotions should be avoided during treatment with a Pavlik harness because these products, in combination with the harness, can cause skin irritation and breakdown. CORRECT ANSWER: "I will place my infant's diapers under the harness straps." To prevent soiling of the harness, the parent should apply the infant's diaper under the straps.

A nurse in an emergency department is caring for an adolescent who has severe abdominal pain due to appendicitis. Which of the following locations should the nurse identify as McBurney's point? (You will find "hot spots" to select in the artwork below. Select only the hot spot that corresponds to your answer.)

A is correct. The nurse should identify this area of the client's abdomen as McBurney's point. This area of the right lower quadrant located about two-thirds of the way between the umbilicus and the client's anterosuperior iliac spine is the area where a client who has appendicitis is most likely to report pain and tenderness.B is incorrect. The nurse should identify this area as the left lower quadrant. Structures of this area of the client's abdomen include the sigmoid colon and part of the descending colon. This area does not contain the appendix, and is therefore not associated with McBurney's point. C is incorrect. The nurse should identify this area as the right upper quadrant. Structures of this area of the client's abdomen include parts of the ascending and transverse colon, liver, and gallbladder. This area does not contain the appendix, and is therefore not associated with McBurney's point.

A nurse is assessing the vital signs of a 10-year-old child following a burn injury. The nurse should identify that which of the following findings is an indication of early septic shock? Blood pressure 130/90 mm Hg Heart rate 60/min Temperature 39.1° C (102.4° F) Urinary output 100 mL/hr

Blood pressure 130/90 mm Hg A blood pressure of 130/90 mm Hg is above the expected reference range of 97 to 128 mm Hg systolic and 58 to 88 mm Hg diastolic for a 10-year-old child. The nurse should expect a child who has early septic shock to have a blood pressure within the expected reference range. Heart rate 60/min A heart rate of 60/min is within the expected reference range of 60 to 100/min when awake and 50 to 90/min when sleeping for a 10-year-old child. The nurse should expect a child who has early septic shock to have a heart rate above the expected reference range. CORRECT ANSWER: Temperature 39.1° C (102.4° F) The nurse should identify that a temperature of 39.1° C (102.4° F) is above the expected reference range of 37° to 37.5° C (98.6° to 99.5° F) for a 10-year-old child. The nurse should expect a child who has early septic shock to have a fever and chills. Urinary output 100 mL/hr Urinary output of 100 mL/hr is above the expected reference range of 33 to 58 mL/hr for a 10-year-old child. The nurse should expect a child who has early septic shock to have urinary output within the expected reference range.

A nurse is reviewing the lumbar puncture results of the school age child who is suspected of having bacterial meningitis. Which of the following findings should the nurse identify as an indication of bacterial meningitis? Decreased cerebrospinal fluid pressure Decreased WBC count Increased protein concentration Increased glucose level

Decreased cerebrospinal fluid pressure Increased cerebrospinal fluid pressure is a finding associated with bacterial meningitis. Decreased WBC count An increased WBC count in the spinal fluid is a finding associated with bacterial meningitis. CORRECT ANSWER: Increased protein concentration The nurse should identify that an increased protein concentration in the spinal fluid is a finding that can indicate bacterial meningitis. Increased glucose level A decreased glucose level in the spinal fluid is a finding associated with bacterial meningitis.

A nurse is admitting a school-age child who has pertussis. Which of the following actions should the nurse take? Place the child in a room with positive-pressure airflow. Place the child in a room with negative-pressure airflow. Initiate contact precautions for the child. Initiate droplet precautions for the child.

Place the child in a room with positive-pressure airflow. The nurse should place a child who has undergone an allogeneic hematopoietic stem cell transplant in a room with positive-pressure airflow to reduce the risk of disease transmission to the child. Place the child in a room with negative-pressure airflow. The nurse should place a child who has an airborne infection, such as measles or varicella, into a room with negative-pressure airflow. Initiate contact precautions for the child. The nurse should initiate contact precautions for a child who has an illness that can be transmitted by direct contact or contact with the child's items, such as hepatitis A and rotavirus. CORRECT ANSWER: Initiate droplet precautions for the child. The nurse should initiate droplet precautions for a child who has pertussis, also known as whooping cough. Pertussis is transmitted through contact with infected large-droplet nuclei that are suspended in the air when the child coughs, sneezes, or talks.

A nurse is providing teaching about play activities for social development to the parents of a preschooler. Which of the following play activities should the nurse recommend for the child? Playing pat-a-cake Using a push-pull toy Creating a scrapbook Playing dress-up

Playing pat-a-cake Playing pat-a-cake is a recommended play activity for an infant. Using a push-pull toy Using a push-pull toy is a recommended play activity for a toddler. Creating a scrapbook Creating a scrapbook is a recommended play activity for a school-age child. CORRECT ANSWER: Playing dress-up The nurse should instruct the parents that at the preschool age, play should focus on social, mental, and physical development. Therefore, playing dress-up is a recommended play activity for this child.

A nurse is caring for a school-age child who is receiving cefazolin via intermittent IV bolus. The child suddenly develops diffuse flushing of the skin and angioedema. After discontinuing the medication infusion, which of the following medications should the nurse administer first? Prednisone Epinephrine Diphenhydramine Albuterol

Prednisone Prednisone is an anti-inflammatory agent that can treat severe inflammation. Although it will benefit a child who is having an anaphylactic reaction, it is not the first medication the nurse should administer. CORRECT ANSWER: Epinephrine This child is most likely experiencing an anaphylactic reaction to the cefazolin. According to evidence-based practice, the nurse should first administer epinephrine to treat the anaphylaxis. Epinephrine is a beta adrenergic agonist that stimulates the heart, causes vasoconstriction of blood vessels in the skin and mucous membranes, and triggers bronchodilation in the lungs. Diphenhydramine Even though histamines are not the major mediators of an anaphylactic reaction, administering an antihistamine such as diphenhydramine can help to decrease the allergic reaction. However, it is not the first medication the nurse should administer. Albuterol Albuterol is a beta adrenergic agonist that can treat acute bronchospasms. Although albuterol will improve the child's breathing, it is not the first medication the nurse should administer.

A nurse is interviewing the parent of an 18 month old toddler during a well child visit. The nurse should identify that which of the following findings indicates a need to assess the toddler for hearing loss? The toddler has a vocabulary of 25 words. The toddler developed a mild rash following a recent varicella immunization. The toddler's Moro reflex is absent. The toddler received tobramycin during a hospitalization 2 weeks ago.

The toddler has a vocabulary of 25 words. At the age of 18 months, the toddler should have a vocabulary of at least 10 words. Therefore, a vocabulary of 25 words does not indicate a need to assess the toddler for hearing loss. The toddler developed a mild rash following a recent varicella immunization. Approximately one in 25 people develop a mild rash following administration of the varicella vaccine. This reaction does not indicate a need to assess the toddler for hearing loss. The toddler's Moro reflex is absent. Primitive reflexes, such as Moro, rooting, and tonic neck, disappear by 5 months of age. Therefore, an absent Moro reflex does not indicate a need to assess the toddler for hearing loss. CORRECT ANSWER: The toddler received tobramycin during a hospitalization 2 weeks ago. The nurse should identify tobramycin as an aminoglycoside, which is an ototoxic medication that can cause mild to moderate hearing loss, and should assess the toddler for a hearing impairment.

A nurse is caring for a toddler who is experiencing acute diarrhea, and has moderate dehydration. Which of the following nutritional items should the nurse offer to the toddler? Apple juice Peanut butter Chicken broth Oral rehydration solution

Apple juice A toddler who has acute diarrhea should not drink apple juice because it is high in carbohydrates and osmolarity and low in electrolytes. Peanut butter A toddler who has acute diarrhea should not eat peanut butter because it is high in carbohydrates and fiber. The high sugar content can result in prolonging the diarrhea and worsening of the dehydration, because water is pulled into the bowel lumen in response to the increased osmolality caused by the sugar. The fiber content further stimulates the bowel, worsening the diarrhea. Chicken broth A toddler who has acute diarrhea should not consume chicken broth because it is high in sodium and is not nutrient-dense. CORRECT ANSWER: Oral rehydration solution A toddler who has acute diarrhea should consume an oral rehydration solution to replace electrolytes and water by promoting the reabsorption of water and sodium. This promotes recovery from dehydration.

A nurse is teaching a school-age who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the child indicates an understanding of the teaching? "I will puncture the pad of my finger when I am testing my blood glucose." "I will give myself a shot of regular insulin 30 minutes before I eat breakfast." "I will eat a snack of 5 grams of carbohydrates if my blood glucose is low." "I will decrease the amount of fluids I drink when I am sick."

"I will puncture the pad of my finger when I am testing my blood glucose." The child should avoid puncturing the pads of the fingers because they have fewer blood vessels and more nerve fibers. Instead, the child should puncture the skin on either side of the finger pad to promote blood flow and decrease pain. CORRECT ANSWER: "I will give myself a shot of regular insulin 30 minutes before I eat breakfast." The child should administer regular insulin 30 min before meals so that the onset coincides with food intake. "I will eat a snack of 5 grams of carbohydrates if my blood glucose is low." The child should eat a snack of 10 to 15 g of carbohydrates, such as 120 mL (4 oz) of fruit juice or 66 g (1/2 cup) of ice cream, to rapidly increase the blood glucose level during a mild hypoglycemic reaction. "I will decrease the amount of fluids I drink when I am sick." During acute illness, the child is prone to hyperglycemia and ketonuria and is at risk for dehydration. Therefore, the child's fluid intake should be increased, rather than decreased.

A hospice nurse is caring for a preschooler who has a terminal illness. One of the preschoolers parents tells the nurse that they cannot cope anymore and are thinking about moving out of the house. Which of the following statements should the nurse make? "It is important that you provide emotional support for your family at this time." "You have to do what you feel is best. Everything will turn out fine." "I know how you feel. This is an extremely stressful time for your family." "Let's talk about some of the ways you have handled previous stressors in your life."

"It is important that you provide emotional support for your family at this time." This statement tells the parent how to behave, which can make them feel as if they must behave as the nurse does and can lead to dependence. "You have to do what you feel is best. Everything will turn out fine." This statement offers false reassurance to the parent, which can invalidate the parent's feelings and cause the parent to become defensive. "I know how you feel. This is an extremely stressful time for your family." This statement is making artificial consolation. These types of statements do not encourage the parent to express their thoughts, concerns, and fears. CORRECT ANSWER: "Let's talk about some of the ways you have handled previous stressors in your life." This statement offers a general lead to allow the parent to express their feelings and previous actions when faced with stressful situations. It also helps the parent to focus on ways that they can cope with the current situation.

A nurse is teaching the guardian of a 6-month-old infant about car seat use .Which of the following statements by the guardian indicates an understanding of the teaching? "I should secure the car seat using lower anchors and tethers instead of the seat belt." "I should position the car seat harness 1 inch above my baby's shoulders." "I will make sure that the car seat is placed at a 90-degree angle." "I will pad my baby's car seat with a blanket for traveling long distances."

CORRECT ANSWER: "I should secure the car seat using lower anchors and tethers instead of the seat belt." Lower anchors and tethers, or the LATCH child safety seat system, should be used to secure an infant's car seat in the vehicle. This system provides anchors between the front cushion and the back rest for the car seat. Therefore, if this system is available, the seat belt does not have to be used. "I should position the car seat harness 1 inch above my baby's shoulders." The car seat harness in rear-facing car seats should be positioned at or just below the infant's shoulders. "I will make sure that the car seat is placed at a 90-degree angle." The car seat should be positioned at a 45° angle to prevent slumping and injury to the infant. "I will pad my baby's car seat with a blanket for traveling long distances." Padding placed underneath the infant or anywhere in the car seat can compress and/or create space between the infant and the harness. This can increase the risk for injury to the infant and should be avoided.

A nurse is reviewing the laboratory report of a school-age child who is experiencing fatigue. Which of the following findings should the nurse recognize as an indication of anemia? Hematocrit 28% Hemoglobin 13.5 g/dL WBC count 8,000/mm3 Platelets 250,000/mm3

CORRECT ANSWER: Hematocrit 28% The nurse should recognize that this hematocrit level is below the expected reference range of 32% to 44% for a school-age child. The child can exhibit fatigue, lightheadedness, tachycardia, dyspnea, and pallor due to the decreased oxygen-carrying capacity. Hemoglobin 13.5 g/dL This hemoglobin level is within the expected reference range of 9.5 to 14 g/dL for a school-age child. WBC count 8,000/mm3 This WBC count is within the expected reference range of 5,000 to 10,000/mm3 for a school-age child. Platelets 250,000/mm3 This platelet count is within with expected reference range of 150,000 to 400,000/mm3 for a school-age child.

After examining the child during hydrotherapy, the provider enters prescriptions into the child's medical record. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the child. Potential Provider's Prescription Change the morphine route to family-controlled analgesia via a PCA pump. Anticipated Contraindicated Obtain a wound culture. Anticipated Contraindicated Place the child on a pressure-reduction mattress. Anticipated Contraindicated Limit daily protein intake. Anticipated Contraindicated The nurse is continuing to care for the child. Nurses' Notes 0800: Child is awake, watching cartoons on TV, and parent is at bedside. IV site in right antecubital is without redness or edema and dressing is dry and intact. Dressings to left arm and hand, anterior neck, and anterior chest are moderately saturated with serous drainage and several small spots of serosanguineous drainage. Dressings remain intact and smell malodorous. Breath sounds are equal and clear bilaterally. Respirations are unlabored. Abdomen is soft and nondistended. Mucous membranes are moist. Skin turgor is slightly brisk. Pupils are equal, round, and reactive to light and accommodation. Child is oriented to place, time, and name. When child attempts to move, they begin to cry. Child reports pain as 8 on the FACES scale. Noted a 1 cm x 2 cm stage 1 pressure injury on the right side of the occiput. Prepared child and parent for transport to hydrotherapy and debridement scheduled for 0830. 0815: Pediatric Burn Unit Nurses' Notes Provider notified of 0800 assessment and vital signs. Provider will examine child during hydrotherapy. Morphine given for pain rating of 8 on FACES pain rating scale. Child transported via stretcher to hydrotherapy for debridement. Hydrotherapy nurse given SBAR report. 0830: Hydrotherapy Nurses' Notes Anesthesia provided. Dressing is removed. Wound on the palm of the left hand has a moderate amount of green drainage with a foul odor. Provider present to examine child. Medication Administration Record 0815: Administered morphine IV 1.7 mg for pain 0830:Administered midazolam IV 1.7 mg upon arrival to hydrotherapy Administered fentanyl IV 17 mcg upon arrival to hydrotherapy

CORRECT ANSWERS: Change the morphine route to family-controlled analgesia via a PCA pump is anticipated. A pain rating of 8 indicates severe pain. The use of a PCA pump should increase the effectiveness of pain management during movement and procedures. The nurse should teach the child's primary caregiver about the use of the PCA pump. Obtain a wound culture is anticipated. The child has an elevated temperature and malodorous green wound drainage. The nurse should obtain a wound culture to determine the causative organism and an antibiotic should be administered. Place the child on a pressure-reduction mattress is anticipated. The child has developed a stage 1 pressure injury on their occiput. A pressure-reduction mattress can help prevent further tissue injury. Limit daily protein intake is contraindicated. Children who have major burns require a high-protein, high-calorie diet to help with wound healing. The nurse should provide high-protein snacks to the child between meals.

A nurse in an emergency department is caring for a school-age child who is experiencing an anaphylactic reaction. Which of the following is the priority action by the nurse? Elevate the head of the child's bed. Insert a large bore IV catheter for the child. Determine the allergen that caused the child's reaction. Administer epinephrine IM to the child. Elevate the head of the child's bed.

Elevating the head of the child's bed is important to facilitate breathing and circulation. However, it is not the priority action the nurse should take. Insert a large bore IV catheter for the child. Inserting a large bore IV catheter is important to facilitate administration of IV fluids and medications. However, it is not the priority action the nurse should take. Determine the allergen that caused the child's reaction. Determining the allergen that caused the child's reaction is important to prevent any additional episodes of anaphylaxis. However, it is not the priority action the nurse should take. CORRECT ANSWER: Administer epinephrine IM to the child. When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority action is administering epinephrine IM to the child. During an anaphylactic reaction, histamine release causes bronchoconstriction and vasodilation. This is an emergency because ultimately this causes decreased blood return to the heart.

A nurse is assessing a school-age child who has meningitis. Which of the following findings is the priority for the nurse to report to the provider? Reports a headache as 6 on a 0 to 10 pain scale Petechiae on the lower extremities Nuchal rigidity Positive Kernig's sign

Reports a headache as 6 on a 0 to 10 pain scale Headache is an expected finding of meningitis; therefore, the nurse should identify a different finding as the priority to report. CORRECT ANSWER: Petechiae on the lower extremities The presence of a petechial or purpuric rash on a child who is ill can indicate the presence of meningococcemia. This type of rash indicates the greatest risk of serious rapid complications from sepsis and should be reported immediately to the provider. Nuchal rigidity Nuchal rigidity is an expected finding of meningitis; therefore, the nurse should identify a different finding as the priority to report. Positive Kernig's sign Positive Kernig's sign is an expected finding of meningitis; therefore, the nurse should identify a different finding as the priority to report.

A nurse is assessing a 3-year-old toddler at a well-child visit. Which of the following manifestations should the nurse report to the provider? Blood pressure 90/50 mm Hg Respiratory rate 45/min Weight 14.5 kg (32 lb) Heart rate 110/min

Blood pressure 90/50 mm Hg The nurse should identify that a blood pressure of 90/50 mm Hg is within the expected reference range of 86 to 118 mm Hg systolic and 44 to 74 mm Hg diastolic for a 3-year-old toddler. CORRECT ANSWER: Respiratory rate 45/min The nurse should identify that a respiratory rate of 45/min is above the expected reference range of 20 to 25/min for a 3-year-old toddler and can indicate respiratory dysfunction and acute respiratory distress. Therefore, the nurse should report this finding to the provider. Weight 14.5 kg (32 lb) The nurse should identify that a weight of 14.5 kg (32 lb) is the average weight for a 3-year-old toddler. Heart rate 110/min The nurse should identify that a heart rate of 110/min is within the expected reference range of 80 to 120/min for a 3-year-old toddler.

A nurse is providing teaching to the parent of a school age child who has a new prescription for oral nystatin for the treatment of oral candidiasis. Which of the following instructions should the nurse include? "Shake the medication prior to administration." "Provide the medication through a straw." "Rinse the child's mouth with water immediately after giving the medication." "Mix the medication with applesauce if the child dislikes the taste."

CORRECT ANSWER: "Shake the medication prior to administration." The nurse should instruct the parent to shake the medication prior to administration to disperse the medication evenly within the suspension. "Provide the medication through a straw." The nurse should instruct the parent to put the medication directly in the child's mouth and make sure the child swishes it around before swallowing. "Rinse the child's mouth with water immediately after giving the medication." The nurse should instruct the parent to have the child keep the medication in their mouth for as long as possible before swallowing it. Rinsing the mouth can wash some of the medication away and decrease its effectiveness. "Mix the medication with applesauce if the child dislikes the taste." The parent should not mix the medication with food because this will interfere with the absorption.

A nurse is caring for a preschooler has been receiving IV fluids via a peripheral IV catheter. When preparing to discontinue the IV fluids and catheter, which of the following actions, should the nurse plan to take? Move the steps into the box on the right, placing them in the order of performance. Use all the steps. Remove the tape securing the catheter Turn off the IV pump Occlude the IV tubing Apply pressure over the catheter insertion site

CORRECT ANSWERS: Turn off the IV pump Occlude the IV tubing Remove the tape securing the catheter Apply pressure over the catheter insertion site First, the nurse should turn off the IV pump. Next, the nurse should occlude the IV tubing, and then remove the tape securing the catheter. Last, the nurse should apply pressure over the catheter insertion site.

A nurse is caring for a school age child who is in bucks traction following a leg fracture 24 hours ago. Which of the following actions should the nurse take? Change the child's position every 2 hr. Clean the peripheral pin sites with chlorhexidine solution every 4 days. Assess peripheral pulses once every 4 hr. Ensure that the head of the bed is elevated to a 90° angle.

Change the child's position every 2 hr. Buck's traction is a type of skin traction that can be used to immobilize extremities prior to surgery. The nurse should maintain the child in a supine position. Clean the peripheral pin sites with chlorhexidine solution every 4 days. Buck's traction is a type of skin traction that can be used to immobilize extremities prior to surgery and does not involve the use of pins. A child who requires skeletal traction will require pin site care. CORRECT ANSWER: Assess peripheral pulses once every 4 hr. Buck's traction is a type of skin traction that can be used to immobilize extremities prior to surgery. The nurse should provide frequent neurovascular checks at least every 4 hr after the first 24 hr of placement in Buck's traction. The nurse should monitor and report signs of neurovascular impairment in the extremities such as cyanosis, edema, pain, absent pulses, and tingling. Ensure that the head of the bed is elevated to a 90° angle. The nurse should maintain the child in a supine position while in Buck's traction. Elevating the head of bed should be implemented for a child who is in cervical traction.

A nurse is caring for a school age child who is receiving a blood transfusion. Which of the following manifestations should alert the nurse to a possible hemolytic transfusion reaction? Laryngeal edema Flank pain Distended neck veins Muscular weakness

Laryngeal edema Laryngeal edema is an indication of an allergic reaction to the blood transfusion. CORRECT ANSWER: Flank pain The nurse should recognize that flank pain is caused by the breakdown of RBCs and is an indication of a hemolytic reaction to the blood transfusion. Distended neck veins Distended neck veins are an indication of circulatory overload, which is a complication of a blood transfusion. Muscular weakness Muscle weakness is an indication of an electrolyte disturbance, which is a complication of a blood transfusion.

The nurse is preparing to collect a sample from a toddler for a sickle turbidity test. Which of the following actions should the nurse plan to take? Obtain a sputum specimen. Perform an Allen test. Perform a finger stick. Obtain a stool specimen.

Obtain a sputum specimen. Sputum specimens are collected to identify the infectious organism in a child who has an acute respiratory tract infection. Therefore, this is not a component of the sickle-turbidity test. Perform an Allen test. An Allen test determines adequate circulation by observing capillary refill before an arterial puncture. Therefore, this is not a component of the sickle-turbidity test. CORRECT ANSWER: Perform a finger stick. The nurse should perform a finger stick on a toddler as a component of the sickle-turbidity test. If the test is positive, hemoglobin electrophoresis is required to distinguish between children who have the genetic trait and children who have the disease. Obtain a stool specimen. Stool specimens are collected to identify organisms or parasites that cause diarrhea or to check for the presence of occult blood. Therefore, this is not a component of the sickle-turbidity test.

A nurse is providing dietary teaching to the parent of a school age child who has celiac disease. The nurse should recommend that the parent offer which of the following foods to the child? Wheat crackers Rye bread Barley soup White rice

Wheat crackers Wheat crackers contain gluten and should be avoided by children who have celiac disease. Rye bread Rye bread contains gluten and should be avoided by children who have celiac disease. Barley soup Barley soup contains gluten and should be avoided by children who have celiac disease. CORRECT ANSWER: White rice The nurse should recommend that the parent offer white rice to the child because it is a gluten-free food. The nurse should instruct the parent that the child will remain on a lifelong gluten-free diet and the child should not consume oats, rye, barley, or wheat, and sometimes lactose deficiency can be secondary to this disease.

A nurse is teaching the parent of an infant about ways to prevent sudden infant death syndrome. SIDS. Which of the following instructions should the nurse include? "Place the infant in a prone position to sleep." "Allow the infant to sleep on a large pillow." "Use a soft mattress in the infant's crib." "Give the infant a pacifier at bedtime."

"Place the infant in a prone position to sleep." The nurse should instruct the parent to place the infant in a supine position to sleep. Prone and side-lying positions are risk factors for SIDS. "Allow the infant to sleep on a large pillow." Placing the infant on a large pillow to sleep can increase the risk of suffocation, asphyxiation, and SIDS. "Use a soft mattress in the infant's crib." The nurse should instruct the parent to use a firm mattress and avoid the use of waterbeds, beanbags, or soft mattresses when placing the infant in bed. The use of a soft mattress in the infant's crib is a risk factor for SIDS and can lead to asphyxiation. CORRECT ANSWER: "Give the infant a pacifier at bedtime." The nurse should inform the parent that protective factors against SIDS include breastfeeding and the use of a pacifier when the infant is sleeping.

A nurse is caring for a preschooler, whose father is going home for a few hours while another relative stays with the child. Which of the following statements should the nurse make to explain to the child when their father will return? "Your daddy will be back at 7 p.m." "Your daddy will be back after he takes care of your brother." "Your daddy will be back in the morning." "Your daddy will be back after you eat."

"Your daddy will be back at 7 p.m." A preschooler does not have an accurate understanding of time. They use language, but most of the time they do not actually know or conceive the meaning of the words. "Your daddy will be back after he takes care of your brother." A preschooler does not have an accurate understanding of time. They use language, but most of the time they do not actually know or conceive the meaning of the words. Also, this response by the nurse does not relate to the child directly. "Your daddy will be back in the morning." A preschooler does not have an accurate understanding of time. They use language, but most of the time they do not actually know or conceive the meaning of the words. CORRECT ANSWER: "Your daddy will be back after you eat." Preschoolers make sense of time best when they can associate it with an expected daily routine, such as meals and bedtime. Therefore, the child comprehends time best when it is explained to them in relation to an event they are familiar with, such as eating.

A nurse is planning care for a school age child who is in the oliguric phase of acute kidney injury AKI, and has a sodium level of 129 mEq per liter. Which of the following interventions should the nurse include in the plan? Administer ibuprofen to the child for a temperature greater than 38º C (100.4º F). Assess the child's blood pressure every 8 hr. Weigh the child weekly at various times of the day. Initiate seizure precautions for the child.

Administer ibuprofen to the child for a temperature greater than 38º C (100.4º F). A child who has AKI can develop a fever due to an infection. Because AKI is a contraindication for receiving medications that are nephrotoxic, such as NSAIDs, the nurse should use compensatory measures, such as turning on a fan in the room. Assess the child's blood pressure every 8 hr. A child who has AKI is often hypertensive due to fluid volume excess and the activation of the renin-angiotensin system. To prevent complications, such as hypertensive encephalopathy, the nurse should assess the child's blood pressure every 4 to 6 hr. Weigh the child weekly at various times of the day. In the oliguric phase of AKI, the child will have decreased urine output and fluid retention. This can result in water intoxication, which predisposes the child to neurologic alterations such as seizures. To ensure accurate evaluation of fluid balance, the nurse should plan to weigh the child daily, at the same time, in the same clothing, and using the same scale. CORRECT ANSWER: Initiate seizure precautions for the child. A sodium level of 129 mEq/L indicates hyponatremia and places the child at increased risk for neurological deficits and seizure activity. The nurse should complete a neurologic assessment and implement seizure precautions to maintain the child's safety.

A nurse is caring for a 15-year-old who is married and is scheduled for a surgical procedure. The client asks, "Who should sign my surgical consent?" Which of the following responses should the nurse make? "You can sign the consent form because you are married." "Your spouse should sign the consent form for you." "Your parent should sign the consent form for you." "You can appoint a legal guardian to sign the consent form."

CORRECT ANSWER: "You can sign the consent form because you are married." The nurse should inform the adolescent that marriage gives adolescents the legal right to consent to surgical procedures and sign other legal documents that they would not otherwise be able to sign due to their age. "Your spouse should sign the consent form for you." The nurse should inform the client that adolescents who are married can sign the consent form and do not require the consent of their spouse. "Your parent should sign the consent form for you." The nurse should inform the client that adolescents who are married can sign the consent form and do not require the consent of a parent. "You can appoint a legal guardian to sign the consent form." The nurse should inform the client that adolescents who are married can sign the consent form and do not require the consent of a legal guardian.

A school nurse is preparing to administer atomoxetine 1.2 mg/kg/day PO to a school-age child who weighs 75 lb. Available is atomoxetine 40 mg/capsule. How many capsules should the nurse administer per day? (Round to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) ____ capsules(s)

CORRECT ANSWER: 1 capsule Follow these steps for the Ratio and Proportion method of calculation: Step 1: What is the unit of measurement the nurse should calculate? kg Step 2: Set up an equation and solve for X. 2.2 lb Client's weight in lb 75 lb / 2.2 lb = X kg X kg = 34.090909 kg Step 3: What is the unit of measurement the nurse should calculate? mg Step 4: Set up an equation and solve for X. X = Dose per kg × Client's weight in kg X mg = 1.2 mg/kg × 34 kg X mg = 40.8 mg Step 5: What is the unit of measurement the nurse should calculate? capsule(s) Step 6: What is the dose the nurse should administer? Dose to administer = Desired 40.8 mg Step 7: What is the dose available? Dose available = Have 40 mg capsule Step 8: Should the nurse convert the units of measurement? No Step 9: What is the quantity of the dose available? 1 capsule Step 10: Set up an equation and solve for X. X capsule(s) = 1.02 capsule Step 11: Round if necessary. 1.02 = 1 capsule Step 12: Determine whether the amount to administer makes sense. If there are 40 mg/capsule and the prescription reads 1.2 mg/kg/day, it makes sense to administer 1 capsule. The nurse should administer atomoxetine 1 capsule PO each day.

A nurse is receiving change of shift report for four children. Which of the following children should the nurse see first? A school-age child who has sickle cell anemia and reports decreased vision in the left eye A school-age child who has cystic fibrosis and a frequent nonproductive cough A preschooler who has asthma and a peak flow meter reading in the green zone An adolescent who has meningitis and reports a sensitivity to lights and noise

CORRECT ANSWER: A school-age child who has sickle cell anemia and reports decreased vision in the left eye When using the urgent vs. non-urgent approach to client care, the nurse should determine the priority finding is a report of decreased vision in the left eye. This finding indicates that the child is experiencing a vaso-occlusive crisis and should be reported to the provider immediately. Therefore, the nurse should see this child first. A school-age child who has cystic fibrosis and a frequent nonproductive cough A frequent nonproductive cough is an expected and non-urgent finding for a child who has cystic fibrosis. Therefore, the nurse should see another child first. A preschooler who has asthma and a peak flow meter reading in the green zone A peak flow meter reading in the green zone is an expected and non-urgent finding for a child who has asthma. Therefore, the nurse should see another child first. An adolescent who has meningitis and reports a sensitivity to lights and noise A sensitivity to light and noise is an expected and non-urgent finding for a child who has meningitis. Therefore, the nurse should see another child first.

A nurse is caring for an infant who has a respiratory syncytial virus RSV. Which of the following actions should the nurse implement for infection control? Have a designated stethoscope in the infant's room. Place the infant in a room equipped with negative airflow. Administer palivizumab as prescribed for the infant. Remove gloves after leaving the infant's room.

CORRECT ANSWER: Have a designated stethoscope in the infant's room. The nurse should initiate droplet precautions for an infant who has RSV because the virus is spread by direct contact with respiratory secretions. Therefore, designated equipment, such as a blood pressure cuff and a stethoscope, should be placed in the infant's room. Place the infant in a room equipped with negative airflow. The nurse should initiate droplet precautions for an infant who has RSV because the virus is spread by direct contact with respiratory secretions. A room equipped with negative airflow is not necessary and is only initiated for infants who need airborne precautions. Administer palivizumab as prescribed for the infant. Palivizumab is used for prophylaxis in at-risk infants and is not used in the treatment of RSV. Remove gloves after leaving the infant's room. The nurse should initiate droplet precautions for an infant who has RSV because the virus is spread by direct contact with respiratory secretions. To reduce the risk of transmission, all health care personnel should remove their gloves prior to leaving the infant's room.

A nurse is reviewing the laboratory report of a seven-year-old child who is receiving chemotherapy which of the following laboratory values should the nurse report to the provider? Hgb 8.5 g/dL WBC count 9,500/mm3 Prealbumin 18 mg/dL Platelets 300,000/mm3

CORRECT ANSWER: Hgb 8.5 g/dL A child receiving chemotherapy is at risk for anemia due to the chemotherapy effects on the blood-forming cells of the bone marrow. The development of anemia is diagnosed through laboratory testing of hemoglobin and hematocrit levels. The nurse should recognize that a hemoglobin level of 8.5 g/dL is below the expected reference range of 10 to 15.5 g/dL for a 7-year-old child and should be reported to the provider. WBC count 9,500/mm3 A child receiving chemotherapy is at risk for infection due to the myelosuppressing effects of the medication used to treat the cancer. The presence of infection can be evaluated through body temperature, redness, edema, warmth, or drainage of wound or IV sites, as well as through measurements of WBC and absolute neutrophil counts. A WBC count of 9,500/mm3 is within the expected reference range of 5,000 to 10,000/mm3 for a 7-year-old child. Prealbumin 18 mg/dL A child receiving chemotherapy is at risk for malnutrition as a result of nausea and vomiting, stomatitis, and pain. Nutritional status can be evaluated through prealbumin, albumin, and transferrin levels. A prealbumin level of 18 mg/dL is within the expected reference range of 15 to 33 mg/dL for a 7-year-old child. Platelets 300,000/mm3 A child receiving chemotherapy is at risk for hemorrhage due to the thrombocytopenic effects of the medications used to treat cancer. The development of thrombocytopenia is diagnosed through laboratory testing of platelet levels. A platelet count of 300,000/mm3 is within the expected reference range of 150,000 to 400,000/mm3 for a 7-year-old child.

A nurse is caring for a school age child who has experienced a tonic, clonic seizure. Which of the following actions should the nurse take during the immediate postictal period? Place the child in a side-lying position. Delay documentation until the child is fully alert. Give the child a high-carbohydrate snack. Administer an oral sedative to the child.

CORRECT ANSWER: Place the child in a side-lying position. The nurse should place the child in a side-lying position to prevent aspiration. Delay documentation until the child is fully alert. To ensure accurate description of the event, the nurse should document the treatment of the seizure and the postictal period as early as possible. Give the child a high-carbohydrate snack. The child should not be given any foods or liquids until protective reflexes have returned to prevent aspiration. Administer an oral sedative to the child. The child should not be given anything by mouth until protective reflexes have returned to prevent aspiration.

A nurse is creating a plan of care for a school-age child who has heart disease and has developed heart failure. Which of the following interventions should the nurse include in the plan? Provide small, frequent meals for the child. Schedule time in the play room for the child. Weigh the child weekly. Maintain the child in a supine position.

CORRECT ANSWER: Provide small, frequent meals for the child. The metabolic rate of a child who has heart failure is high because of poor cardiac function. Therefore, the nurse should provide small, frequent meals for the child because it helps to conserve energy. Schedule time in the play room for the child. The nurse should restrict play activities to the child's bed to minimize energy expenditure. Weigh the child weekly. The nurse should weigh the child daily. Maintain the child in a supine position. To provide for maximum chest expansion, the nurse should maintain the child's bed in a semi-Fowler's position.

A nurse is caring for an adolescent, who received a kidney transplant. Which of the following findings should the nurse identify as an indication the adolescent is rejecting the kidney? Negative leukocyte esterase Serum creatinine 3.0 mg/dL Negative urine protein Urine output 40 mL/hr

CORRECT ANSWER: Serum creatinine 3.0 mg/dL Creatinine is a byproduct of protein metabolism and is excreted from the body through the kidneys. An elevated serum creatinine level, therefore, can be an indication that the kidneys are not functioning. The nurse should identify that the adolescent's serum creatinine level is higher than the expected reference range of 0.4 to 1.0 mg/dL for an adolescent and can indicate rejection of the kidney. Negative urine protein The nurse should identify that a negative urine protein is an expected finding and does not indicate rejection of the kidney. Urine output 40 mL/hr. The nurse should identify that a urine output of 40 mL/hr is within the average hourly urine output of 33 to 62.5 mL/hr for an adolescent and does not indicate rejection of the kidney.

After reviewing the information in the medical record, the nurse should identify that the child is at risk for developing which of the following conditions? Complete the following sentence by using the list of options: The nurse should identify that the child is at risk for developing ________ as evidenced by _________. at risk for developing: acute post-streptococcal glomerulonephritis (APSGN) splenomegaly dysrhythmias as evidenced by: positive mononucleosis rapid test urinary output cardiovascular assessment Vital Signs 0715: Temperature 38.3° C (100.9° F) Heart rate 126/min Respiratory rate 26/min Pulse oximeter 97% Physical Examination 0715:Guardians report that the child has been tired lately and has been experiencing a sore throat and fever. Child is tolerating sips of liquids, but is refusing solid foods. Guardians report that the child is voiding dark yellow urine. 0730:Child is alert and responsive to verbal stimuli. Mucous membranes are dry and sticky. Skin turgor without tenting. Tonsils enlarged and erythematous. Respirations are regular and non-labored. No accessory muscle use noted. Lungs clear anterior and posterior bilaterally. Point of maximum intensity (PMI) in the left mid-clavicular line 4th intercostal space. Heart rate is regular without murmurs, gallops, or rubs. Radial and pedal pulse 2+ bilaterally. Capillary refill greater than 2 seconds. Abdomen flat and non-distended. Bowel sounds active in all four quadrants. Extremities are warm and dry to the touch. Diagnostic Results 0900: Mononucleosis rapid test: positive (negative)

CORRECT ANSWER: The nurse should identify that the child is at risk for developing splenomegaly as evidenced by positive mononucleosis rapid test. Dropdown 1: Splenomegaly is correct. The child's positive mononucleosis rapid test result indicates the presence of infectious mononucleosis, a condition caused by the Epstein-Barr virus. Therefore, the nurse should identify that the child is at risk for developing splenomegaly, a common complication of infectious mononucleosis. Acute poststreptococcal glomerulonephritis (APSGN) and dysrhythmias are incorrect. APSGN can occur following a streptococcal infection. A positive mononucleosis rapid test indicates that the child has mononucleosis, which is caused by the Epstein-Barr virus, rather than streptococcus bacteria. The child's cardiovascular assessment reflects expected findings for a preschooler. Therefore, there is no indication that the child is at risk for developing dysrhythmias. The child's cardiovascular assessment reflects expected findings for a preschooler. Therefore, there is no indication that the child is at risk for developing dysrhythmias. Dropdown 2: Positive mononucleosis rapid test is correct. The child's positive mononucleosis rapid test result indicates the presence of infectious mononucleosis, a condition caused by the Epstein-Barr virus. Therefore, the nurse should identify that the child is at risk for developing splenomegaly, a common complication of infectious mononucleosis. Urinary output and cardiovascular assessment are incorrect. Although decreased urine output is a potential indication of APSGN, this finding can also be caused by dehydration. The child is experiencing other manifestations of dehydration, including decreased oral intake, fever, tachycardia, tachypnea, and dry mucous membranes. The child's cardiovascular assessment reflects expected findings for a preschooler. Therefore, there is no indication that the child is at risk for developing dysrhythmias.

A nurse in a provider's office is preparing to administer immunizations to a toddler during a well-child visit. Which of the following actions should the nurse plan to take? Withhold the measles, mumps, and rubella (MMR) vaccine Withhold the diphtheria, tetanus, and pertussis (DTaP) vaccine Withhold the influenza vaccine Withhold the tuberculin skin test (TST). Provider Prescriptions Tuberculin skin test (TST) Measles, mumps, and rubella (MMR) vaccine Inactivated influenza vaccine Diphtheria, tetanus, and pertussis (DTaP) vaccine Graphic Record Respiratory rate 24/min Heart rate 115/min temperature 36.9° C (98.4° F) History and Physical​ Age 15 monthsHeight 71.1 cm (28 in) Allergies Neomycin (anaphylactic reaction) Caregiver reports rhinitis with clear nasal drainage for 2 days Occasional nonproductive cough for 2 days History of asthma

CORRECT ANSWER: Withhold the measles, mumps, and rubella (MMR) vaccine. The nurse should recognize that an allergy to neomycin with an anaphylactic reaction is a contraindication for receiving the MMR vaccine. Clients who have a severe allergy to eggs or gelatin should not receive this vaccine. Withhold the diphtheria, tetanus, and pertussis (DTaP) vaccine. It is safe to administer the DTaP vaccine at the same time as the MMR vaccine and tuberculin skin test (TST). DTaP vaccines are not contraindicated for children who have mild acute illness or asthma. Withhold the influenza vaccine. A child who has asthma can receive the inactivated influenza vaccine. Withhold the tuberculin skin test (TST). It is safe to perform a TST at the same time as administering MMR and varicella vaccines. A TST is not contraindicated for children who have mild acute illness or asthma.

A nurse is providing teaching to the parent of an infant who has diaper dermatitis. The nurse should instruct the parent to apply which of the following to the affected area? Zinc oxide Antibiotic ointment Talcum powder Antiseptic solution

CORRECT ANSWER: Zinc oxide Diaper dermatitis is a common inflammatory skin disorder caused by contact with an irritant such as urine, feces, soap, or friction, and takes the form of scaling, blisters, or papules with erythema. Providing a protective barrier, such as zinc oxide, against the irritants allows the skin to heal. Antibiotic ointment Diaper dermatitis can be the result of an overgrowth of yeast, such as Candida albicans, on the skin. Treatment for yeast-related dermatitis includes a topical antifungal medication. However, antibiotic ointment is not recommended for the treatment of diaper dermatitis. Talcum powder Diaper dermatitis can be treated with several different products at the same time, including a protective ointment and a protective powder, such as a powder made with karaya or cornstarch. However, talcum powder is not recommended for the treatment of diaper dermatitis because it has been linked to respiratory disorders in infants. Antiseptic solution Infants who have diaper dermatitis should have the affected areas gently washed with water and a mild soap. Antiseptic solution is not recommended because this can cause burning and pain to the infant.

The nurse is providing discharge teaching to the child and their parent 36 days after admission. Select 6 statements by the parent that indicate an understanding of the discharge teaching. "I will give my child hydroxyzine to prevent bacterial infection." "I should apply a moisturizer to the scar tissue." "I will use a measured spoon or medicine cup to give my child hydroxyzine." "I can give my child hydroxyzine every 6 hours as needed." "Puppet play can be helpful for my child." "I should avoid giving hydroxyzine at bedtime." "I will avoid massaging the scar tissue." "My child is too young to be concerned about their body image." "I need to assess for any redness or open skin areas before applying my child's left arm splint." "My child will need to use a compression garment to decrease blood supply to the scarred tissue." Nurses' Notes 0900: Home care consultation and supply delivery arrangements completed by the child's case manager. 1400: Provided discharge teaching to the parent and child regarding medications, skin and wound care, and psychosocial needs. Parent verbalized understanding of teaching.

CORRECT ANSWERS: "I should apply a moisturizer to the scar tissue" is correct. Frequent application of a non-perfume moisturizer should be applied to the scar tissue to help reduce itching the child might experience. "I will use a measured spoon or medicine cup to give my child hydroxyzine" is correct. All liquid medications should be administered with a measured spoon or cup to provide an accurate amount of the prescribed dose of medication. "I can give my child hydroxyzine every 6 hours as needed" is correct. Hydroxyzine is administered every 6 to 8 hr each day as needed. "Puppet play can be helpful for my child" is correct. Preschoolers engage in imaginative play. The use of puppets will encourage the child to express their feelings through imaginary play. "I need to assess for any redness or open skin areas before applying my child's left arm splint" is correct. It is important that the child's skin be assessed for redness, open areas, or blisters prior to putting on a splint. The splint is used to prevent contractures of the extremities and promote normal alignment during the healing process. Because the splint might be worn for a long period of time, the child's growth might cause the splint to not fit properly and can cause a pressure injury. "My child will need to use a compression garment to decrease blood supply to the scarred tissue" is correct. Using a compression garment on the scar tissue decreases the blood supply to avoid nourishing the hypertrophic tissue. It also forces the collagen into a more normal alignment. Compression garments are worn during the healing of the burned tissue and should be worn as much as possible. "I will give my child hydroxyzine to prevent bacterial infection" is incorrect. Hydroxyzine is an antihistamine, not an antibiotic, and is prescribed for pruritus. Scar tissue can cause intense itching while it is healing. It is important the child does not scratch the healing wounds. "I should avoid giving hydroxyzine at bedtime" is incorrect. Giving hydroxyzine at bedtime can help reduce scratching while sleeping. An adverse effect of hydroxyzine is drowsiness. Therefore, administering it at bedtime will not interfere with the child's sleep. "I will avoid massaging the scar tissue" is incorrect. Massage therapy is beneficial in helping to stretch the scar tissue and prevent contractures. Massage therapy can be done during application of a skin moisturizer. "My child is too young to be concerned about their body image" is incorrect. Body image begins to develop during the preschool years. They understand the meaning of pretty or ugly and reflect the opinion of those around them. Therefore, the parent needs to help the child form positive thoughts about how they look.

Which of the following statements by guardian indicate that the discharge teaching was effective? Select all that apply. "We should apply a skin emollient immediately after bathing our child." "We should keep our child's fingernails trimmed short." "We should rub the sores vigorously to remove scabs." "We should allow our child to take a bubble bath prior to bed." "We should use a mild detergent for our laundry." "We should apply a large amount of the ointment to the sores." Nurses' Notes 0915: Guardians report that lately the child has had severe itching and is breaking out with sores on their eyebrows, wrists, and ankles. The "sores started to bleed." Guardians report no relief with the application of the topical hydrocortisone cream. 0930: The child is alert. Multiple small erythematous papules with some scaling noted on the child's eyebrows, forearms, and lower legs bilaterally. 1015: Provider in to evaluate the child. Discharge to home after medication administration of new prescriptions and discharge teaching for atopic dermatitis. Medical History Family history of atopic dermatitis Medication Administration Record 1000:Loratadine (oral solution) 5 mg PO daily. Administer first dose now prior to discharge. Tacrolimus 0.03% ointment. Apply thin layer to affected areas twice daily; rub in gently and completely. Return to primary care provider in 1 to 2 weeks for evaluation.

CORRECT ANSWERS: "We should apply a skin emollient immediately after bathing our child" is correct. An emollient is an oil that moisturizes the skin and should be applied immediately after bathing while the skin is damp to prevent drying. Therefore, this statement by the guardian indicates the teaching has been effective. "We should keep our child's fingernails trimmed short" is correct. The child's fingernails and toenails should be kept short, trimmed, and filed to prevent scratching with sharp edges. Therefore, this statement by the guardian indicates the teaching has been effective. "We should use a mild detergent for our laundry" is correct. The use of mild detergents for laundry helps prevent allergens and itching. Therefore, this statement by the guardian indicates the teaching has been effective. "We should rub the sores vigorously to remove scabs" is incorrect. The sores or lesions should be patted dry after bathing, rather than scrubbed vigorously. The scabs should not be removed because this could cause infection. Therefore, this statement by the guardian indicates the need for further teaching. "We should allow our child to take a bubble bath prior to bed" is incorrect. The use of bubble baths and powders should be avoided because this can cause skin irritation. Therefore, this statement by the guardian indicates the need for further teaching. "We should apply a large amount of the ointment to the sores" is incorrect. Tacrolimus is a topical steroid that should only be applied in a thin layer. Therefore, this statement by the guardian indicates the need for further teaching.

A nurse is caring for a toddler who has spastic (pyramidal) cerebral palsy. Which of the following findings should the nurse expect? (Select all that apply.) Negative Babinski reflex Ankle clonus Exaggerated stretch reflexes Uncontrollable movements of the face Contractures

CORRECT ANSWERS: Ankle clonus. The nurse should expect a child who has spastic cerebral palsy to exhibit ankle clonus, which is a rhythmic reflex tremor when the foot is dorsiflexed. Exaggerated stretch reflexes. The nurse should expect a child who has spastic cerebral palsy to exhibit spasticity or exaggerated stretch reflexes. Contractures. The nurse should expect a child who has spastic cerebral palsy to exhibit contractures due to the tightening of the muscles. Negative Babinski reflex is incorrect. The nurse should expect a child who has spastic cerebral palsy to exhibit a positive Babinski reflex. Uncontrollable movements of the face is incorrect. The nurse should expect a child who has nonspastic (dyskinetic) cerebral palsy, rather than spastic (pyramidal) cerebral palsy to exhibit uncontrollable movements of the face and extremities.

A nurse on a pediatric unit is caring for a school-age child. After reviewing the information in the child's medical record, which of the following findings should the nurse report to the provider? Select the 4 findings that the nurse should report to the provider. Arterial blood gases Cardiovascular assessment WBC count Hemoglobin Oxygen saturation level Respiratory assessment Nurses' Notes 0830:Child is alert and responsive to stimuli. Skin is warm and dry. Capillary refill less than 3 seconds. Respirations regular and shallow. Mild intercostal retractions noted. Expiratory wheezes auscultated in the anterior and posterior lung bases. Abdomen is soft, flat, and non-distended. 1100:Child appears restless. Moderate intercostal retractions noted. Scattered rhonchi anterior bases with wheezing noted on inhalation and exhalation. Point of maximum intensity (PMI) in the left mid-clavicular line 4th intercostal space. Heart rate is regular without murmurs, gallops, or rubs. Radial and pedal pulse 2+ bilaterally. Vital Signs 0830:Temperature 37.1° C (98.8° F) Heart rate 100/min Respiratory rate 22/min Blood pressure 90/60 mm Hg Pulse oximetry 97% on 2 L of oxygen via nasal cannula 1100:Temperature 37.1° C (98.8° F) Heart rate 110/min Respiratory rate 30/min Pulse oximetry 94% on 2 L of oxygen via nasal cannula Diagnostic Results 1200: CBC: Hemoglobin 10 g/dL (10 to 15.5 g/dL) Hematocrit 32% (32% to 44%) WBC count 11,000/mm3 (5,000 to 10,000/mm3) Arterial Blood Gases (ABGs): pH 7.49 (7.35 to 7.45) PCO2 32 mm Hg (35 to 45 mm Hg) HCO3- 24 mEq/L (21 to 28 mEq/L) PO2 92 mm Hg (80 to 100 mm Hg) Medical History Asthma

CORRECT ANSWERS: Arterial blood gases is correct. The child's arterial blood gases (ABGs) indicate respiratory alkalosis, which is associated with complications of asthma, such as hyperventilation and hypoxia. Therefore, the nurse should report these findings to the provider. Oxygen saturation level is correct. The child's oxygen saturation level has decreased below the expected reference range despite the use of supplemental oxygen. Therefore, the nurse should report this finding to the provider. Respiratory assessment is correct. The child's respiratory assessment indicates increased respiratory distress, as evidenced by the presence of tachypnea, retractions, and increased wheezing. Therefore, the nurse should report these findings to the provider. WBC count is correct. The child's WBC count is above the expected reference range, which could be an indication of infection or inflammation. Therefore, the nurse should report this finding to the provider. Cardiovascular assessment is incorrect. The child's cardiovascular assessment reflects expected findings for a school-age child. Therefore, there is no indication that the nurse should report these findings to the provider. Hemoglobin is incorrect. The child's hemoglobin is within the expected reference range. Therefore, there is no indication that the nurse should report this finding to the provider.

After reviewing the child's assessment, which of the following findings should the nurse address first? Complete the following sentence by using the lists of options. The nurse should first address the client's Select... temperatures saturated dressing urine output blood pressure respiratory status followed by the client's Select... pain sensorium nutrition drainage on the dressing fluid status . The nurse is caring for the child 4 days after admission Graphic Record 0800: Temperature 38.8° C (101.8° F)Heart rate 124/minRespiratory rate 22/minBlood pressure 100/56 mm HgSaO2 97% on room airWeight 17.1 kg (37.7 lb)Urine output 15 mL in past hour Nurses' Notes 0800: Child is awake, watching cartoons on television, and parent is at bedside. IV site in right antecubital is without redness or edema and dressing is dry and intact. Dressings to left arm and hand, anterior neck, and anterior chest are moderately saturated with serous drainage and several small spots of serosanguineous drainage. Dressings remain intact and smell malodorous. Breath sounds are equal and clear bilaterally. Respirations are unlabored. Abdomen is soft and nondistended. Mucous membranes are moist. Skin turgor is slightly brisk. Pupils are equal, round, and reactive to light and accommodation. Child is oriented to place, time, and name. When child attempts to move, they begin to cry. Child reports pain as 8 on the FACES scale. Noted a 1 cm x 2 cm stage 1 pressure injury on the right side of the occiput. Prepared child and parent for transport to hydrotherapy and debridement scheduled for 0830. Nurses' Notes 0800: Child is awake, watching cartoons on television, and parent is at bedside. IV site in right antecubital is without redness or edema and dressing is dry and intact. Dressings to left arm and hand, anterior neck, and anterior chest are moderately saturated with serous drainage and several small spots of serosanguineous drainage. Dressings remain intact and smell malodorous. Breath sounds are equal and clear bilaterally. Respirations are unlabored. Abdomen is soft and nondistended. Mucous membranes are moist. Skin turgor is slightly brisk. Pupils are equal, round, and reactive to light and accommodation. Child is oriented to place, time, and name. When child attempts to move, they begin to cry. Child reports pain as 8 on the FACES scale. Noted a 1 cm x 2 cm stage 1 pressure injury on the right side of the occiput. Prepared child and parent for transport to hydrotherapy and debridement scheduled for 0830. Provider Prescriptions 0800: Daily debridement of burn wounds in the hydrotherapy tub Dressings with silver sulfadiazine impregnated gauze and secured in mesh net placed over dressing twice daily Encourage PO full liquids. Consult dietitian. Morphine IV 1.7 mg every 2 to 4 hr as needed for pain Midazolam IV 1.7 mg 5 min before hydrotherapy Fentanyl IV 17 mcg 3 min before hydrotherapy Fentanyl IV 8.5 mcg every 3 to 5 min PRN during debridement

CORRECT ANSWERS: Dropdown 1: Temperature is correct. When using the urgent vs. nonurgent approach to client care, the nurse should determine that an increased temperature is a priority finding, because it can indicate an infection and sepsis. Wound sepsis is most likely to occur between the third and fifth day after a burn. Therefore, the nurse should first address the child's temperature. Saturated dressing, urine output, blood pressure, and respiratory status are incorrect. When using the urgent vs. nonurgent approach to client care, the nurse should identify that a moderately saturated dressing is an expected finding at this time of wound healing due to a shift of fluids and leaky capillaries. When using the urgent vs. nonurgent approach to client care, the nurse should identify that urine output should be 0.5 to 1 mL/kg in children. This child weighs 17.1 kg. Therefore, 15 mL/hr is within the expected reference range. When using the urgent vs. nonurgent approach to client care, the nurse should identify that the child's blood pressure is within the expected reference range and is not a concern at this time. When using the urgent vs. nonurgent approach to client care, the nurse should identify that the child's respiratory status is within the expected reference range. Therefore, the nurse should address another finding first. Dropdown 2: Pain is correct. When using the urgent vs. nonurgent approach to client care, the nurse should determine that an 8 out of 10 pain rating on the FACES scale is a priority finding and should be addressed next. Severe pain impacts the stress response, which can lead to complications and adversely affect healing. Sensorium, nutrition, drainage on dressing, and fluid status are incorrect. When using the urgent vs. nonurgent approach to client care, the nurse should identify that there are no findings to indicate a change in the child's sensorium. Change in sensorium can be an early manifestation of shock and should be monitored. However, the child's neurological status and sensorium findings are expected for a child this age. When using the urgent vs. nonurgent approach to client care, the nurse should identify that although good nutrition is essential to wound healing, decreased nutrition is common in children who have major burns. When using the urgent vs. nonurgent approach to client care, the nurse should identify that serosanguinous and serous fluid at this time of wound healing is an expected finding. Serosanguinous and serous fluid do not indicate active uncontrolled bleeding and are not a concern. When using the urgent vs. nonurgent approach to client care, the nurse should identify that there are no findings to indicate either a decrease or excess of fluid volume.

Which of the following potential provider prescriptions should the nurse identify as anticipated or contraindicated? For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the child. Potential Provider's Prescription Anticipated Contraindicated Apply sterile gauze soaked with cool 0.9% sodium chloride to the burn areas. Insert an indwelling urinary catheter. Provide 100% oxygen via face mask. Weigh the child. A nurse in an emergency department is caring for a 4-year-old child who was rescued from a home fire by emergency medical services (EMS). History and Physical 4-year-old child was in a house fire and rescued by EMS. Child has partial-thickness and full-thickness burns on their left arm, hand, anterior neck, and upper left side of the anterior chest. Total body surface area (TBSA) estimated to be 18%. Child is awake and crying. Lungs are clear bilaterally. Has a non-productive cough. Graphic Record Temperature 37.7° C (99.9° F) Heart rate 150/min Respiratory rate 32/min Blood pressure 100/52 mm Hg SaO2 89% on room air

CORRECT ANSWERS: Insert an indwelling urinary catheter is anticipated. Inserting an indwelling urinary catheter is essential and allows for accurate measurement of urine output. Urine output is an indicator of the fluid status of the child. A child who has major burns will lose a significant amount of fluid due to increased capillary permeability, which increases the risk for hypovolemic shock. It is important to maintain accurate hourly I&O to manage fluid replacement. Provide 100% oxygen via face mask is anticipated. Upon admission to the emergency department, the nurse should recognize the need to provide 100% oxygen via face mask as an essential prescription. The child's SaO2 is below the expected reference range and their respiratory rate is increased. Weigh the child is anticipated. The nurse should recognize the need to weigh the child as essential. Children of the same age weigh different amounts. The amount of fluid resuscitation and medication a pediatric patient receives is based on their weight. Apply sterile gauze soaked with cool 0.9% sodium chloride to the burn areas is contraindicated. Applying sterile gauze soaked with cool 0.9% sodium chloride to a child who has 18% TBSA might cause hypothermia. The nurse should cover the burn with a clean, dry cloth to prevent contamination and hypothermia.

A nurse in an emergency department is caring for a 4-year-old child who was rescued from a home fire by emergency medical services (EMS). The nurse should identify that which of the following findings require immediate follow-up? Select the 3 findings that require immediate follow-up. Child is awake and crying Partial- and full-thickness burns to the left upper anterior chest and anterior neck Non-productive cough SaO2 89% on room air Heart rate 150/min Temperature 37.7° C (99.9° F) Blood pressure 100/52 mm Hg History and Physical 4-year-old child was in a house fire and rescued by EMS. Child has partial-thickness and full-thickness burns on their left arm, hand, anterior neck, and upper left side of the anterior chest. Total body surface area (TBSA) estimated to be 18%. Child is awake and crying. Lungs are clear bilaterally. Has a non-productive cough. Graphic Record Temperature 37.7° C (99.9° F)Heart rate 150/minRespiratory rate 32/minBlood pressure 100/52 mm HgSaO2 89% on room air

CORRECT ANSWERS: Partial- and full-thickness burns to the left upper anterior chest and anterior neck is correct. Airway, breathing, and circulation are the immediate concerns. Burns to the chest and neck require immediate follow-up due to a concern for inhalation injury. In addition, the edema of the tissue in the neck can compromise the airway and severe burns to the chest can impede the child's ability to expand their chest during inspiration, causing respiratory distress. SaO2 89% on room air is correct. Airway, breathing, and circulation are the immediate concerns. The nurse should immediately follow-up on the low oxygen saturation level. Hypoxia can be a manifestation of respiratory distress or shock. Therefore, this finding needs immediate attention. Heart rate 150/min is correct. Airway, breathing, and circulation are the immediate concerns. The nurse should immediately follow-up on the child's increased heart rate. Tachycardia is a manifestation of shock. Children with major burns can develop hypovolemic shock due to fluid loss. Child is awake and crying is incorrect. This is an expected finding for a 4-year-old child who has experienced a traumatic event. It also indicates the child is not exhibiting a change in sensorium and their airway is not occluded. The pain from the partial-thickness burns will need to be assessed and managed, but airway, breathing, and circulation are the immediate concerns. Non-productive cough is incorrect. Airway, breathing, and circulation are the immediate concerns. A non-productive cough does not require immediate follow-up. The nurse should assess for signs of inhalation burns or injury. One of the manifestations of inhalation injury the nurse should assess for is carbonaceous secretions, which indicate burned saliva. Temperature 37.7° C (99.9° F) is incorrect. Airway, breathing, and circulation are the immediate concerns. A temperature of 37.7° C (99.9° F) is within the expected reference range and does not require immediate follow-up. The child's temperature will need to be monitored closely for hypothermia and hyperthermia. Blood pressure 100/52 mm Hg is incorrect. Airway, breathing, and circulation are the immediate concerns. A blood pressure of 100/52 mm Hg is within the expected reference range for a 4-year-old child and does not require immediate follow-up. Most children have the ability to compensate and can maintain their blood pressure in the early stages of shock.

The child has returned to the unit following the procedure. Which of the following actions should the nurse take? Select all that apply. Monitor SaO2 every 2 hr. Provide 100% oxygen via face mask. Check anterior neck and chest dressing for bleeding. Replace the dressing on the left thigh. Place a warm blanket on the child. Keep the child's head in a neutral position. The nurse is caring for the child 14 days after admission. Graphic Record 0800:Temperature 37° C (98.6° F)Heart rate 100/minRespiratory rate 20/minBlood pressure 98/56 mm HgSaO2 97% on room airWeight 16.8 kg (37 lb)1300:Temperature 35.8° C (96.4° F)Heart rate 68/minRespiratory rate 14/minBlood pressure 90/50 mm HgSaO2 88% on room air Nurses' Notes Pediatric Burn Unit 0800: Reinforced preoperative teaching with the child and parent. Child is awake and alert. Moving all extremities. Child limits their range-of-motion of the left arm. Anterior neck and upper chest dressings are dry and intact. Left arm and hand dressings are intact and slightly moist with serous drainage. Breath sounds are clear and equal bilaterally. Abdomen is soft and nondistended. Bowel sounds are active in all quadrants. Child remains NPO for surgery. Right antecubital peripherally inserted central catheter (PICC) line dressing is dry and intact. Site is without redness, edema, or drainage. IV maintenance fluids and PCA morphine are infusing through PICC line. Child reports pain as 2 on the FACES pain scale.PACU Nurse 1245: Anterior neck and left chest dressings are dry and intact. Left thigh dressing has a moderate amount of bloody drainage. Breath sounds are clear and equal bilaterally. Respirations are easy, unlabored, and shallow. Oxygen discontinued and SaO2 remains at 94% to 96% on room air. PICC line remains intact with IV maintenance fluids infusing. Dressing is dry and intact. No redness, edema or drainage noted at insertion site. Child is awake and crying. Parent at bedside. Child reports pain as 8 on the FACES pain scale. IV morphine bolus given via PICC line. Child transported to pediatric burn unit.Pediatric Burn Unit 1300: Child returns from the PACU. SBAR report received from PACU nurse. Child is difficult to arouse. Arouses to repeated loud noise and moderate tactile stimulation by opening eyes briefly. Respirations are unlabored and very shallow. Breath sounds are clear and equal bilaterally. No cyanosis noted. Neck and left anterior chest dressings are dry and intact. Left thigh dressing has a moderate amount of bloody drainage. IV maintenance fluids infusing via PICC line. Provider Prescriptions 0800:Surgical placement of permanent skin graft of the anterior neck and left anterior chest Maintain IV of dextrose 5% in 0.9% sodium chloride at 56 mL/hr. Discontinue PCA morphine upon transport to surgical suite.

CORRECT ANSWERS: Provide 100% oxygen via face mask is correct. The nurse should provide 100% oxygen via face mask to the child because of their SaO2 and respiratory rate. The SaO2 should be maintained at 95% or higher and if the SaO2 falls below 95%, supplemental oxygen should be initiated. Check anterior neck and chest dressing for bleeding is correct. Upon return from the procedure, all surgical dressings should be assessed for drainage and to ensure the dressing is intact. Place a warm blanket on the child is correct. The child is exhibiting hypothermia. It is important for the child to have a stable body temperature because vasoconstriction can diminish blood flow to the surgical sites and impair healing. Keep the child's head in a neutral position is correct. The child's head should be kept in a neutral alignment to prevent hyperextension or hyperflexion and to prevent graft loss. Replace the dressing on the left thigh is incorrect. The nurse should not remove the dressing from the left thigh. Surgical dressings should not be removed from the donor site (left thigh) to avoid damage to the fragile epithelium. The dressing can be reinforced if necessary. Monitor SaO2 every 2 hr is incorrect. The nurse should continuously monitor the child's SaO2 until it is stable. The child's SaO2 on arrival to the unit is below the expected reference range and is a concern that needs to be addressed.

A nurse in an emergency department is performing a physical assessment on a two week old male newborn. Which of the following findings is the priority for the nurse to report to the provider? Excoriated scrotal area Multiple capillary hemangiomas Depressed posterior fontanel Substernal retractions

Excoriated scrotal area The nurse should report an excoriated scrotal area to the provider. However, there is another finding that is the nurse's priority to report. Multiple capillary hemangiomas The nurse should report the presence of multiple capillary hemangiomas to the provider. However, there is another finding that is the nurse's priority to report. Depressed posterior fontanel The nurse should report a depressed posterior fontanel to the provider. However, there is another finding that is the nurse's priority to report. CORRECT ANSWER: Substernal retractions When using the airway, breathing, and circulation approach to client care, the nurse should determine that the priority finding to report to the provider is substernal retractions. This finding indicates the newborn is experiencing increased respiratory effort, which could quickly progress to respiratory failure.

A school nurse is assessing an adolescent who has multiple burns in various stages of healing. Which of the following behaviors should the nurse identify as a possible indication of physical abuse? Describes strong relationships with peers Expresses a reluctance to leave home Provides a detailed description of how the burns occurred Denies discomfort during assessment of injuries

Expresses a reluctance to leave home The nurse should suspect child maltreatment in the form of physical abuse if the adolescent expresses a reluctance to return home or demonstrates a fear of parents. Provides a detailed description of how the burns occurred The nurse should suspect child maltreatment in the form of physical abuse if the adolescent's description of the injury is vague and inconsistent with the actual wounds. CORRECT ANSWER: Denies discomfort during assessment of injuries The nurse should suspect child maltreatment in the form of physical abuse if the adolescent has a blunted response to painful stimuli or injury. Describes strong relationships with peers The nurse should suspect child maltreatment in the form of physical abuse if the adolescent has withdrawn behavior and poor relationships with peers.

A nurse is assessing a 4-year-old child visit. Which of the following developmental milestones should the nurse expect to observe? Identifies right from left hand Uses a utensil to spread butter Cuts an outlined shape using scissors Draws a stick figure with seven body parts

Identifies right from left hand Identifying the right from left hand is an expected developmental milestone of a 6-year-old child. Uses a utensil to spread butter Using a utensil to spread butter is an expected developmental milestone of a 6-year-old child. CORRECT ANSWER: Cuts an outlined shape using scissors The nurse should recognize that an expected developmental milestone of a 4-year-old child is using scissors to cut out a shape. Draws a stick figure with seven body parts Drawing a stick figure with seven body parts is an expected developmental milestone of a 5-year-old child.

A school nurse is assessing an adolescent who has scoliosis. Which of the following findings should the nurse expect? Increase in anterior convexity of the lumbar spine Increased curvature of the thoracic spine Lateral flexion of the neck A unilateral rib hump

Increase in anterior convexity of the lumbar spine An increased anterior convexity of the lumbar spine is a manifestation of lordosis, an expected finding in toddlers. Lordosis can indicate a complication of a disease process, such as flexion contractures, congenital dislocation of the hip, or obesity, when seen in older children. Increased curvature of the thoracic spine An increased curvature of the thoracic spine is a manifestation of kyphosis. Kyphosis can be a manifestation of a congenital condition or disease process such as rickets, or it can be posture-related. In posture-related kyphosis, the adolescent presents with rounded shoulders and a slouching posture. Lateral flexion of the neck Lateral flexion of the neck is an indication of torticollis as a result of contracture of the sternocleidomastoid muscle. Torticollis can be congenital, the result of intrauterine fetal posturing or abnormality of the cervical spine, or it can be acquired, due to factors such as a traumatic lesion to the sternocleidomastoid muscle. CORRECT ANSWER: A unilateral rib hump When assessing an adolescent for scoliosis, the school nurse should expect to see a unilateral rib hump with hip flexion. This results from a lateral S- or C-shaped curvature to the thoracic spine resulting in asymmetry of the ribs, shoulders, hips, or pelvis. Scoliosis can be the result of a neuromuscular or connective tissue disorder, or it can be congenital in nature.

A nurse in an emergency department is caring for a toddler who has partial-thickness burns on the right arm. Which of the following actions should the nurse take? Insert a nasogastric tube. Initiate prophylactic antibiotic therapy. Cleanse the affected area with mild soap and water. Apply a topical corticosteroid to the affected area.

Insert a nasogastric tube. The nurse should be aware that inserting a nasogastric tube to empty the contents of the stomach and maintain decompression is an intervention for major burn management. Initiate prophylactic antibiotic therapy. The nurse should be aware that antibiotics are not routinely administered for the prevention of infection at the burn site because the decreased circulation in the burned area decreases the distribution of the medication to the deeper tissues. CORRECT ANSWER: Cleanse the affected area with mild soap and water. The nurse should wash the affected area with mild soap and water to remove any loose tissue that could cause infection. Apply a topical corticosteroid to the affected area. The nurse should apply an antimicrobial ointment to the affected area to prevent infection.

A nurse in an emergency department is caring for a school-age child who has appendicitis and rates their abdominal pain as 7 on a scale of 0 to 10. Which of the following actions should the nurse take? Instill a 500 mL tap water enema. Give morphine 0.05 mg/kg IV. Administer polyethylene glycol 1g/kg PO. Apply a heating pad to the child's abdomen.

Instill a 500 mL tap water enema. Administering an enema accelerates bowel motility and increases the risk for perforation of the appendix. CORRECT ANSWER: Give morphine 0.05 mg/kg IV. A pain level of 7 on a scale of 0 to 10 is considered severe. The nurse should administer an analgesic medication for pain relief. Administer polyethylene glycol 1g/kg PO. Administering laxatives accelerates bowel motility and increases the risk for perforation of the appendix. Apply a heating pad to the child's abdomen. Applying heat to the child's abdomen increases the risk for perforation of the appendix.

Nurse is planning care for a toddler who has a serum lead level of 4 µg per deciliter. Which of the following actions should the nurse plan to take? Instruct the parents to decrease the calcium in their toddler's diet. Prepare the toddler for chelation therapy. Refer the family to Child Protective Services. Schedule the toddler for a yearly re-screening.

Instruct the parents to decrease the calcium in their toddler's diet. The nurse should instruct the toddler's parents to provide a diet rich in calcium because calcium, vitamin C, and iron decrease lead absorption. Prepare the toddler for chelation therapy. Chelation therapy is required for a lead level of 45 mcg/dL or greater and, depending on the situation, can be initiated for lead levels over 10 mcg/dL. Refer the family to Child Protective Services. A serum lead level of 4 mcg/dL does not require a report to Child Protective Services because it is not an indicator of child endangerment. CORRECT ANSWER: Schedule the toddler for a yearly re-screening. The nurse should schedule the toddler for a lead level re-screening in 1 year and educate the family on ways to prevent exposure.

A nurse is providing discharge teaching to the parents of a child who is one week postoperative following a cleft palate repair. For which of the following members of the interprofessional team, should the nurse initiate a referral? Occupational therapist Speech therapist Respiratory therapist Physical therapist

Occupational therapist The nurse should initiate a referral for an occupational therapist for a child who has physical disabilities and requires assistance with ADLs. CORRECT ANSWER: Speech therapist The nurse should initiate a referral for a speech therapist for a child who is postoperative following a cleft palate repair. A child who has a cleft palate will require speech therapy immediately following the repair to support speech development and future articulation. Respiratory therapist The nurse should initiate a referral for a respiratory therapist for a child who requires airway support. Physical therapist The nurse should initiate a referral for a physical therapist for a child who requires assistance with mobility and increasing physical strength.

A nurse is preparing to administer an immunization to a 4-year old child. Which of the following actions should the nurse plan to take? Place the child in a prone position for the immunization. Request that the child's caregiver leave the room during the immunization. Administer the immunization using a 24-gauge needle. Inject the immunization slowly after aspirating for 3 seconds.

Place the child in a prone position for the immunization. The nurse should place the child in an upright sitting position for the immunization because this decreases the child's fear and anxiety. Request that the child's caregiver leave the room during the immunization. The nurse should allow the caregiver to stay near the child during the immunization to provide a sense of security and reduce the child's anxiety level. CORRECT ANSWER: Administer the immunization using a 24-gauge needle. The nurse should administer an immunization for a 4-year-old child using a 22- to 25- gauge needle to minimize the amount of pain the child experiences. Inject the immunization slowly after aspirating for 3 seconds. The nurse should inject the immunization rapidly and avoid aspiration. These actions decrease the risk of needle displacement and lower the child's fear and anxiety level by decreasing the amount of time it takes to administer the immunization.

A nurse is creating a plan of care for an infant who has an epidural hematoma from a head injury. Which of the following interventions should the nurse include in the plan? Position the infant side-lying with their head at a 0° to 5° angle. Perform a neurological assessment every 4 hr. Suction the infant's nares to remove secretions. Implement seizure precautions for the infant.

Position the infant side-lying with their head at a 0° to 5° angle. The nurse should position the infant with their head slightly elevated in a midline position to reduce the risk of increased intracranial pressure. Perform a neurological assessment every 4 hr. The nurse should perform a neurological assessment as frequently as every 15 min to detect changes in the child's condition and monitor for intracranial pressure. Suction the infant's nares to remove secretions. The nurse should avoid suctioning the infant's nares due to the risk of exposure of the suction catheter to the brain through the fracture; however, oral suctioning can be performed. CORRECT ANSWER: Implement seizure precautions for the infant. An infant who has an epidural hematoma is at great risk for seizure activity. Therefore, the nurse should implement seizure precautions for the child.

A nurse is reviewing the laboratory report of an infant who is receiving treatment for severe dehydration. The nurse should identify that which of the following laboratory values indicates the effectiveness of the current treatment? Potassium 2.9 mEq/L Sodium 140 mEq/L Urine specific gravity 1.035 BUN 25 mg/dL

Potassium 2.9 mEq/L A potassium level of 2.9 mEq/L is below the expected reference range of 4.1 to 5.3 mEq/L and indicates hypokalemia. CORRECT ANSWER: Sodium 140 mEq/L The nurse should identify that a sodium level of 140 mEq/L is within the expected reference range of 134 to 150 mEq/L and indicates the current treatment regimen the infant is receiving for dehydration is effective. Urine specific gravity 1.035 A urine specific gravity of 1.035 is above the expected reference range of 1.005 to 1.030 and indicates concentrated urine. BUN 25 mg/dL A BUN level of 25 mg/dL is above the expected reference range of 5 to 18 mg/dL and indicates the kidneys are not excreting BUN as they should be.

A charge nurse in an emergency department is preparing an in-service for a group of newly licensed nurses about the manifestations of child maltreatment. Which of the following manifestations should the charge nurse include as a potential indication of physical abuse? Recurrent urinary tract infections Symmetric burns of the lower extremities Failure to thrive Lack of subcutaneous fat

Recurrent urinary tract infections Recurrent urinary tract infections are a clinical manifestation that can indicate sexual abuse. CORRECT ANSWER: Symmetric burns of the lower extremities The nurse should include that symmetric burns to the lower extremities can indicate physical abuse. The patterns are usually characteristic of the method or object used, such as cigar or cigarette burns, or burns in the shape of an iron. Failure to thrive Failure to thrive can be an indication of physical neglect due to malnutrition. Lack of subcutaneous fat Lack of subcutaneous fat can be an indication of physical neglect. This manifestation can be a result of poor health care, infections that were untreated, and/or a lack of or delayed childhood immunizations.

A nurse is assessing a toddler who has gastroenteritis and is exhibiting manifestations of dehydration. Which of the following findings is the nurses priority? Skin breakdown Hypotension Hyperpyrexia Tachypnea

Skin breakdown Toddlers who have gastroenteritis and are dehydrated are at increased risk for skin breakdown because of changes in circulation and loss of skin elasticity. However, there is another finding that is the nurse's priority. Hypotension Toddlers who have gastroenteritis and are dehydrated can exhibit hypotension because of reduced blood volume. However, there is another finding that is the nurse's priority. Hyperpyrexia Toddlers who have gastroenteritis and are dehydrated can exhibit hyperpyrexia, or fever, which is caused by the effect of fluid volume depletion on the hypothalamus. However, there is another finding that is the nurse's priority. CORRECT ANSWER: Tachypnea When using the airway, breathing, and circulation approach to client care, the nurse's priority finding is the toddler's tachypnea. Tachypnea is a result of the kidneys being unable to excrete hydrogen ions and produce bicarbonate, which leads to metabolic acidosis.

A nurse is caring for a school-age child who is receiving chemotherapy and is severely immunocompromised. Which of the following actions should the nurse take? Infuse packed RBCs Use surgical asepsis when providing routine care for the child. Administer the measles, mumps, and rubella (MMR) vaccine to the child. Screen the child's visitors for indications of infection.

Use surgical asepsis when providing routine care for the child. It is not necessary for the nurse to use surgical asepsis when providing direct care. Strict hand hygiene and medical asepsis are recommended to prevent the spread of infection. Administer the measles, mumps, and rubella (MMR) vaccine to the child. The MMR vaccine is contraindicated for a child who is severely immunocompromised because it is a live virus vaccine and the child might not be able to build adequate antibodies to prevent infection with the organism. CORRECT ANSWER: Screen the child's visitors for indications of infection. A child who is severely immunocompromised is unable to adequately respond to infectious organisms, resulting in the potential for overwhelming infection. Therefore, the nurse should screen the child's visitors for indications of infection. Infuse packed RBCs. A child who is immunocompromised as a result of chemotherapy will have a decreased neutrophil count. The nurse should plan to infuse packed RBCs for the child who is anemic. However, packed RBCs will not increase the child's neutrophil count.