ATI Nursing care of Children Practice Tests

A nurse is reinforcing discharge teaching with the parent of a school-age child who is being treated for nephrotic syndrome. The parent asks the nurse why it is necessary to check the child's urine for protein. Which of the following explanations should the nurse offer?

"A decrease in urine protein indicates that treatment is effective." The desired outcome of steroid therapy in the treatment of nephrotic syndrome is a reduction of proteinuria.

A nurse is reinforcing dietary teaching with the parent of a 2-year-old toddler. Which of the following should the nurse include in the teaching?

"An appropriate serving size is 1 tablespoon of food per year of age." The nurse should include that an appropriate serving size for a 2-year-old toddler is 1 tbsp of food per year of age.

A nurse is reinforcing teaching with the family of a preschooler whose parent has a terminal diagnosis. Which of the following statements should the nurse include when discussing age-appropriate responses to death?

"At this age, your child likely believes his thoughts can cause another person's death." The nurse should reinforce that, at this age, the preschooler might believe that his thoughts can cause another person's death, which can make him feel guilty or responsible for the death.

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?

"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 reinforcing teaching with the parent of an infant who has a new diagnosis of human immunodeficiency virus (HIV). Which of the following statements made by the parent indicates an understanding of the teaching?

"I should bring my child in for immunizations on schedule." Immunizations provide protection from communicable diseases and should be administered on schedule.

A nurse is reinforcing teaching about interventions for mild hypoglycemia with the parent of a child who has diabetes mellitus. Which of the following statements by the parent indicates that the teaching has been effective?

"I should give my child 4 ounces of orange juice followed by cheese and crackers." The parent should treat mild hypoglycemia with 10 to 15 g of a simple carbohydrate, such as 4 oz of orange juice, and follow it with a starch-protein snack.

A nurse is providing teaching to the parent of a preschooler about ways to prevent acute asthma attacks. Which of the following statements by the parent should the nurse identify as understanding the teaching "I will use a humidifier in my child's room at night." "I will give my child a cough suppressant every six hours if he has a cough." "I should avoid using a wet mop on my floors when I am cleaning." "I should keep my child indoors when I mow the yard."

"I should keep my child indoors when I mow the yard

A nurse is teaching the parent of a preschooler about ways to prevent acute asthma attacks. Which of the following statements by the parent indicates an understanding of the teaching?

"I should keep my child indoors when I mow the yard." The nurse should instruct the parent to keep the preschooler indoors during lawn maintenance or when the pollen count is increased. Guarding against exposure to known allergens found outdoors, such as grass, tree, and weed pollen, will decrease the frequency of the preschooler's asthma attacks.

A nurse is reinforcing teaching about injury prevention with the guardian of an infant. Which of the following statements by the guardian indicates an understanding of the teaching?

"I should make sure my baby's clothing does not have buttons on it." The nurse should instruct the guardian to avoid dressing the infant in clothing with buttons to reduce the risk of choking and aspiration.

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." Lower anchors and tethers, or the LATCH child safety seat system, should be used to secure an infant's car seat in the vehicle. This system provides anchors between the front cushion and the back rest for the car seat. Therefore, if this system is available, the seat belt does not have to be used.

A nurse is reinforcing teaching about sudden infant death syndrome (SIDS) with the parent of a 1-month-old infant. Which of the following statements by the parent indicates an understanding of the teaching?

"I will allow my baby to have a pacifier while sleeping." The nurse should reinforce with the parent that allowing the infant to fall asleep with a pacifier in his mouth decreases the risk for SIDS.

A nurse is teaching a school-age child 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 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.

A nurse is reinforcing teaching about liquid oral supplements with the guardian of a school-age child who has iron deficiency anemia. Which of the following statements by the guardian indicates an understanding of the teaching?

"I will give this medication to my child with a straw." The nurse should reinforce with the guardian to administer this medication with a straw to prevent staining the child's teeth.

A nurse is reinforcing discharge teaching with the guardian of a child who has juvenile idiopathic arthritis (JIA). Which of the following statements by the parent indicates an understanding of the teaching?

"I will have my child sleep in knee, wrist, and hand splints." The nurse should reinforce with the guardian that splinting the child's joints at night will decrease pain and enhance joint function.

A nurse is reinforcing discharge teaching with the guardian of a school-age child who has a new prescription for home oxygen therapy. Which of the following statements by the guardian indicates an understanding of the teaching?

"I will make sure that electrical devices in the house are grounded." This response by the guardian indicates an understanding of the nurse's instructions. Due to the combustible nature of oxygen, all pieces of electrical equipment in the home should be grounded to decrease the risk of a fire caused by an electrical spark.

A nurse is reinforcing teaching about home care with the guardian of a 14-month-old toddler who has spastic cerebral palsy. Which of the following statements by the guardian indicates an understanding of the teaching?

"I will perform daily stretching exercises to my toddler's affected muscles." The nurse should reinforce that performing stretching exercises of the toddler's affected muscles will prevent muscle contractures.

A nurse is reinforcing teaching about home safety with the parent of a toddler. Which of the following parent statements indicates an understanding of the teaching?

"I will place a screen in front of the fireplace." The nurse should instruct the parent to place a screen in front of a fireplace or other heating appliances to prevent burns.

A nurse is teaching the parent of an infant who has a Pavlik harness for the treatment of developmental dysplasia of the hip. The nurse should identify that which of the following statements by the parent indicates an understanding of the teaching?

"I will place my infant's diapers under the harness straps." To prevent soiling of the harness, the parent should apply the infant's diaper under the straps.

A nurse is reinforcing discharge teaching with the guardian of a school-age child who has acute lymphocytic leukemia and an absolute neutrophil count of 450/mm3. Which of the following instructions should the nurse include?

"Keep your child away from crowded areas." The nurse should instruct the guardian to keep the child away from crowds and visitors who have an illness to decrease the risk for infection.

A nurse is caring for an adolescent client who is a practicing Jehovah's Witness and is scheduled for surgery for a ruptured appendix. The adolescent tells the nurse that based on her religious beliefs, she cannot receive a blood transfusion. Which of the following responses should the nurse make?

"Let's discuss the possibility of you needing a blood transfusion with your parents." The nurse should offer to involve the child's parents to understand the family's beliefs about blood transfusions.

A hospice nurse is caring for a preschooler who has a terminal illness. The father tells the nurse that he cannot cope anymore and has decided to move out of the house. Which of the following statements should the nurse make?

"Let's talk about some of the ways you have handled previous stressors in your life." 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 in a pediatric clinic is talking on the telephone with the parent of a 6-month-old infant who has a UTI and started taking an oral antibiotic the day before. Listen to the (audio clip) and determine which of the following responses the nurse should make?

"Mix the medicine with 1 teaspoon of applesauce before giving it to your baby." To enhance acceptance of an oral medication, the parent can mix the medication with a small amount of a sweet, nonessential food item.

A nurse in a pediatric clinic is caring for an infant who has heart failure and a prescription for digoxin. Which of the following statement by the parent indicates the desired therapeutic effect of the medication?

"My baby is breathing easier than she used to." The nurse should identify that the desired effect of digoxin is to increase cardiac output and decrease venous pressure and pulmonary edema, which will reduce respiratory demands.

A nurse is reinforcing teaching regarding the immunization schedule of a newborn. Which of the following statements made by the parent should the nurse recognize as an understanding of the newborn's immunization schedule?

"My baby will receive his next immunization when he is 2 months old." Newborns should receive the next scheduled immunization 2 months after birth.

A nurse is reinforcing teaching regarding the immunization schedule with the parent of a 6-month-old infant during a well-baby visit. Which of the following statements by the parent indicates an understanding of the teaching?

"My baby will receive his third DTaP vaccine today." The nurse should reinforce with the parent that the infant should receive his third diphtheria, tetanus, and pertussis (DTaP) immunization at 6 months of age.

A nurse in a provider's office is caring for a preschooler who has findings of croup. Which of the following statements by the parent requires immediate intervention by the nurse?

"My child has refused to drink any fluids for the past 8 hours." An inadequate fluid intake indicates the child is at greatest risk for dehydration and electrolyte imbalance. Therefore, this statement by the parent requires immediate intervention by the nurse.

A nurse is reinforcing teaching with the guardian of a child who has a new prescription for levalbuterol solution for use in a nebulizer. Which of the following statements by the guardian indicates an understanding of the teaching?

"My child might experience palpitations after taking this medication." Palpitations are an adverse effect of levalbuterol. If this occurs, the guardian should discontinue the medication and notify the provider.

A nurse is reinforcing teaching with the guardian of a child who has a new diagnosis of rheumatic fever. Which of the following statements by the guardian indicates an understanding of the teaching?

"My child might have a period of irregular movement of the extremities." The nurse should instruct the guardian that the child might experience chorea weeks or months after the initial diagnosis. Chorea is a temporary lack of coordination and the presence of sudden, irregular movements or periods of clumsiness.

A nurse is preparing to administer the measles, mumps, and rubella (MMR) vaccine to a preschooler. The nurse should recognize which of the following statements by the parent as a contraindication to receiving the immunization?

"My child received an immunoglobulin last month." The nurse should identify that a preschooler who received an immunoglobulin less than 1 month ago should not receive the MMR vaccine on this day. The nurse should instruct the parent to reschedule the immunization after 3 months have elapsed, since the child received passive immunity via administration of an immunoglobulin.

A nurse is teaching the parents of a school-age child who has a new diagnosis of osteomyelitis of the tibia. The nurse should identify that which of the following statements by the parents indicates an understanding of the teaching?

"My child will receive antibiotics for several weeks." The nurse should instruct the parent that the child will receive antibiotic therapy for at least 4 weeks. Surgery might be indicated if the antibiotics are not successful.

A nurse is reinforcing teaching about vital signs with the guardian of a 1-year-old toddler. Which of the following statements by the guardian indicates an understanding of the teaching?

"My child's pulse could increase to 150 beats a minute with activity." A pulse rate of 150/min is within the expected reference range for a toddler during physical activity.

A nurse is caring for a school-age girl who is being treated for frequent, severe UTI's. The nurse should recognize that which of the following statements by the parent indicates a possible cause of the UTI's?

"My daughter has bowel movements every 4 to 5 days." The nurse should recognize that this frequency indicates the child is constipated. Therefore, large stool masses might prevent complete emptying of the bladder and lead to urinary stasis and infection.

A nurse is reinforcing teaching about glucose monitoring with the parent of a child who has type 1 diabetes mellitus. Which of the following instructions should the nurse include in the teaching?

"Put your child's finger under warm, running water prior to collecting blood." The nurse should instruct the parent that placing the child's finger under warm, running water increases the blood flow to the finger, which will make it easier to obtain the sample.

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." The nurse should instruct the parent to shake the medication prior to administration to disperse the medication evenly within the suspension.

A guardian calls the clinic nurse after his child has developed symptoms of varicella and asks when his child will no longer be contagious. Which of the following responses should the nurse make?

"Six days after lesions appear if they are crusted." The nurse should inform the guardian that a child will stop being contagious around 6 days after the lesions appeared, as long as they are crusted over.

A nurse is caring for a toddler who has terminal cancer and is receiving hospice care. The child's parent tells the nurse, "I'm a bad parent, and I can't deal with this." Which of the following responses should the nurse make?

"Tell me more about what you are feeling." The nurse should use open-ended statements that will allow the parent to share his feelings and emotions. During times of grief, the parent needs to express his emotions. The use of an open-ended statement relays the message that it is safe to do so with the nurse.

A nurse is reinforcing teaching with the guardian of a child who has scabies and a new prescription for permethrin 5% cream. Which of the following information should the nurse include?

"The medication will eliminate your child's itching within 2 to 3 weeks." The nurse should instruct the guardian that, although the medication kills the mites, itching can continue for 2 to 3 weeks following application of the medication.

A nurse is reinforcing home safety instructions with the parents of a toddler. Which of the following parent statements indicates an understanding of the teaching?

"We will turn the pot handles toward the back of the stove." The nurse should instruct the parents to turn pot handles toward the back of the stove to prevent the toddler from pulling a pot off the stove, resulting in a burn.

A nurse is caring for a 15 year-old client 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." 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.

A nurse is reinforcing teaching with an adolescent female client who has acne vulgaris and a new prescription for isotretinoin. Which of the following information should the nurse include?

"You will need to have two negative pregnancy tests prior to starting this medication." The nurse should reinforce with the client that isotretinoin is teratogenic. Pregnancy must be ruled out prior to administration and before each subsequent refill. The client should use two effective forms of contraception while taking this medication.

A nurse is reinforcing teaching with an adolescent who has an inflamed, nonperforated appendix and is scheduled for a laparoscopic assisted appendectomy. Which of the following instructions should the nurse include in the teaching?

"You will sit in your chair at least twice a day after surgery." The nurse should instruct the client that she will sit in a bedside chair at least twice a day and will be encouraged to ambulate as soon as possible following surgery. This activity will enhance lung function and help prevent postoperative complications.

A nurse is caring for a preschooler whose father is going home for a few hours while another relative stays with the child. Which of the following statements should the nurse make to explain to the child when their father will return?

"Your daddy will be back after you eat." Preschoolers make sense of time best when they can associate it with an expected daily routine, such as meals and bedtime. Therefore, the child comprehends time best when it is explained to them in relation to an event they are familiar with, such as eating.

A nurse is caring for a toddler who has spastic (pyramidal) cerebral palsy. Which of the following findings should the nurse expect? (Select all that apply.)

-Ankle clonus -Exaggerated stretch reflexes -Contractures

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

1

A school nurse is preparing to administer atomoxetine 1.2 mg/kg/day PO to a school aged child who weights 75 lbs. Available is atomoxetine 40 mg/capsule. How many capsules should the nurse administer per day?

1 capsule

A nurse is reinforcing dietary teaching with an adolescent who is a lacto-vegetarian and has iron deficiency anemia. The nurse should recommend which of the following as the best source of iron?

1 cup (8 oz) shredded wheat cereal The nurse should determine that shredded wheat cereal is an iron-fortified food. Therefore, it is the best option to recommend because it contains 1 g of iron per serving.

A nurse is preparing to administer phenobarbital to a toddler who has a seizure disorder and weighs 10 kg (22 lb). The prescription reads phenobarbital sodium 2.5 mg/kg PO BID. Available is phenobarbital 20 mg/5 mL. How many mL should the nurse administer with each dose?

6.25 mL

A nurse is caring for a school-age child who has been admitted to the facility in sickle cell crisis. The nurse is measuring the child's oral intake for the shift. The child consumed 4 oz of juice at breakfast. For lunch, the child consumed 6 oz of milk, 6 oz of gelatin, and drank 7 oz of water. What is the child's oral intake for this shift in mL?

690 mL 1 oz = 30 mL

A nurse has just received change-of-shift report for four children in a pediatric unit. Which of the following children should the nurse collect data from first?

A child who has a fever and nuchal rigidity A client who has a fever and nuchal rigidity is unstable. This finding indicates bacterial meningitis, which requires urgent data collection and intervention to reduce complications for the child and prevent further spread of the infection. Therefore, the nurse should collect data from this child first.

A nurse is receiving change-of-shift report on four children. Which of the following children should the nurse see first?

A school-age child who has sickle cell anemia and reports decreased vision in the left eye. When using the urgent vs. nonurgent approach to client care, the nurse should determine the priority finding is a report of decreased vision in the left eye. This finding indicates that the child is experiencing a vaso-occlusive crisis and should be reported to the provider immediately. Therefore, the nurse should see this child first.

A school nurse is assessing an adolescent who has scoliosis. Which of the following findings should the nurse expect?

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 the emergency department is assessing a toddler who has Kawasaki disease. Which of the following findings should the nurse expect? (Select all that apply A. Increased temperature B. Gingival hyperplasia C. Xerophthalmia D. Bradycardia E. Cervical lymphadenopathy

A, C, E increased temperature is correct. Kawasaki disease is an acute illness associated with a fever lasting more than 4 days that is unresponsive to antipyretics or antibiotics. Gingival hyperplasia is incorrect. Children who have Kawasaki disease develop a strawberry tongue, cracked lips, and edema of the oral mucosa and pharynx. A child who is receiving phenytoin therapy can develop gingival hyperplasia. Xerophthalmia is correct. Ophthalmic manifestations of Kawasaki disease include reddening of the conjunctiva and dryness of the eyes, or xerophthalmia. Bradycardia is incorrect. Kawasaki disease is an infection that affects the vascular system, including the heart. The nurse should expect the child to be tachycardic with a gallop rhythm. Long term effects of Kawasaki disease include the development of coronary artery aneurysms or myocardial infarction. Cervical lymphadenopathy is correct. The child who has Kawasaki disease may develop enlarged cervical nodes on one side of the neck that are nontender and greater than 1.5 cm in size.

A nurse is teaching the mother of a 6-month-old infant about teething. Which of the following statements should the nurse make A. Your baby may pull at her ears when she is teething." B. "Rub your baby's gums with an aspirin to decrease her discomfort." C. "Place a beaded teething necklace around your baby's neck." D. "Your baby's upper middle teeth will erupt first."

A. "Your baby may pull at her ears when she is teething

A nurse is providing anticipatory guidance to the parents of a 2-week-old infant about risk factors for sudden infant death syndrome (SIDS). Which of the following risk factors should the nurse include in the teaching A. Covering the sleeping infant with a blanket B. Supine sleeping C. Maternal history of milk allergy D. Pacifier use during sleep

A. Covering the sleeping infant with a blanket

A nurse is caring for a school-age child who has diabetes mellitus and was admitted with a diagnosis of diabetic ketoacidosis. When performing the respiratory assessment, which of the following findings should the nurse expect A. Deep respirations of 32/min B. Shallow respirations of 10/min C. Paradoxic respirations of 26/min D. Periods of apnea lasting for 20 seconds

A. Deep respirations of 32/min: The nurse should expect deep and rapid respirations in a child who has diabetic ketoacidosis. This respiratory rhythm is the body's attempt to blow off excess carbon dioxide and achieve a state of homeostasis.

A nurse is reviewing laboratory results of a school-age child who is 1 week postoperative following an open fracture repair. Which of the following values should the nurse identify as an indication of a potential complication A. Erythrocyte sedimentation rate 18 mm/hr B. WBC 6,200/mm3 C. C-reactive protein 1.4 mg/L D. RBC 4.7 106/µL

A. Erythrocyte sedimentation rate 18 mm/hr: An erythrocyte sedimentation rate of 18 mm/hr is above the expected reference range and is an indication of osteomyelitis.

A nurse is assessing an infant who has a ventricular septal defect. Which of the following findings should the nurse expect A. Loud, harsh murmur B. Dysrhythmias C. Weak femoral pulses D. High blood pressure

A. Loud, harsh murmur

A nurse is teaching a group of parents about infectious mononucleosis. Which of the following statements by a parent should the nurse identify as understanding the teaching A. Mononucleosis is caused by an infection with the Epstein-Barr virus." B. Mononucleosis is a bacterial infection requiring 14 days of antibiotics." C. "A Monospot is a throat culture used to diagnosis mononucleosis." D. "Children who get mononucleosis will need to refrain from sports for 6 months."

A. Mononucleosis is caused by an infection with the Epstein-Barr virus

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 A. Place the child in a lateral position. B. Delay documentation until the child is fully alert. C. Give the child a high-carbohydrate snack. D. Administer an oral sedative to the child.

A. Place the child in a lateral position

A nurse is caring for an infant who is receiving IV fluids for the treatment of Tetralogy of Fallot and begins to have a hypercyanotic spell. Which of the following actions should the nurse take A. Place the infant in a knee-chest position. B. Administer a dose of meperidine IV. C. Discontinue administration of IV fluids. D. Apply oxygen at 2 L/min via nasal cannula.

A. Place the infant in a knee-chest position: The nurse should place the infant in a knee-chest position during a hypercyanotic spell to decrease the return of desaturated venous blood from the legs and to direct more blood into the pulmonary artery by increasing systemic vascular resistance.

A nurse is assessing a 6-month-old infant at a well-infant visit. Which of the following findings should the nurse report to the provider A. Presence of strabismus B. Presence of corneal light reflex C. Presence of open anterior fontanel D. Presence of cerumen

A. Presence of strabismus: Strabismus, or crossing of the eyes, disappears at 3 to 4 months of age. Therefore, the nurse should report this finding to the provider.

A nurse is planning an educational program for school-age children and their parents about bicycle safety. Which of the following information should the nurse plan to include A. The child should be able to stand on the balls of her feet when sitting on the bike. B. The child should ride her bike 2 feet to the side of other bike riders. C. The child should wear dark-colored clothing with a fluorescent stripe when riding at night. D. The child should ride the bike facing traffic when it is necessary to ride in the street.

A. The child should be able to stand on the balls of her feet when sitting on the bike

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?

A. 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.

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

A. 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.

A nurse is reviewing the laboratory report of a 6-year-old child who is receiving chemotherapy. Which of the following laboratory values should the nurse report to the provider A. Hgb 8.5 g/dL B. WBC 9,500/mm3 C. Prealbumin18 mg/dL D. Platelets 300,000/mm3

A. hgb 8.5 The 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 for a 6-year-old child and should be reported to the provider.

A nurse is assessing a toddler who has leukemia and is receiving his first round of chemotherapy. Which of the following findings is the priority for the nurse to report to the provide A. Urticaria B. Fatigue C. Vomiting D. Anorexia

A. urticaria

A nurse in an emergency department is auscultating the lungs of an adolescent who is experiencing dyspnea. The nurse should identify the sound as which of the following? (Click on the audio button to listen to the clip A. Wheezes B. Crackles C. Pleural friction rub D. Rhonchi

A. wheezes

The nurse is assessing a school-age child who has peritonitis. Which of the following findings should the nurse expect?

Abdominal distension The nurse should identify that abdominal distention is an expected finding of peritonitis. Peritonitis is an inflammation of the lining of the abdominal wall. This inflammation in the abdomen, along with the ileus that develops, causes abdominal distention. Other manifestations include chills, irritability, and restlessness.

A nurse is assessing a school-age child immediately following a perforated appendix repair. Which of the following findings should the nurse expect?

Absence of peristalsis The nurse should expect absence of peristalsis immediately following a perforated appendix repair, until the bowel resumes functioning.

A nurse is caring for a preschooler who is scheduled for hydrotherapy treatment for wound debridement following a burn injury. Which of the following actions should the nurse take prior to the procedure?

Administer an analgesic to the child. Hydrotherapy for debridement of a wound is an extremely painful procedure which requires analgesia and/or sedation. When pain is controlled, it leads to reduced physiological demands on the body caused by stress and decreases the likelihood of children developing depression and post-traumatic stress disorder.

A nurse is caring for a toddler who has otitis media and a temperature of 39.1 C (102.4 F). Which of the following actions should the nurse take first?

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

A nurse in an emergency department is caring for a school-age child who is experiencing an anaphylactic reaction. Which of the following is the priority action by the nurse?

Administer epinephrine IM to the child. 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 assisting with a sterile dressing change for an adolescent who has a partial thickness burn on the right hip. Which of the following actions should the nurse take first?

Administer pain medication to the client. According to evidence-based practice, the nurse should first provide pain medication to the client to reduce discomfort during the procedure.

A nurse is preparing to administer an immunization to a 4-year-old child. Which of the following actions should the nurse plan to take?

Administer the immunization using a 24-gauge needle. The nurse should administer an immunization for a 4-year-old child using a 22- to 25- gauge needle to minimize the amount of pain the child experiences.

A nurse is caring for a preschooler who has a new diagnosis of asthma. Which of the following medications should the nurse instruct the parent to administer for an acute asthma attack?

Albuterol The nurse should inform the parent to administer albuterol, a short-acting beta2 agonist, to the preschooler for acute asthma attacks.

A nurse is reinforcing teaching with the parents of a child who has cystic fibrosis and is taking pancrelipase as a pancreatic enzyme replacement. The nurse should plan to inform the child's parents that the therapeutic effects of this medication can be evaluated by which of the following?

Amount and consistency of stools Recording the amount and consistency of the child's stools will help determine the effectiveness of pancrelipase, which is taken to decrease the bulk of feces.

A nurse is collecting data from an infant during a well-child visit. Which of the following sites should the nurse use when obtaining the infant's heart rate?

Apical The nurse should use the apical pulse to obtain the infant's heart rate and count it for a full minute, because it gives a reliable rate and rhythm and provides accurate baseline assessment data. In an infant, the apical heart rate is auscultated at the fourth intercostal space lateral to the midclavicular line.

A nurse is reinforcing dietary teaching about a low-sodium diet with the parents of a child who is recovering from acute glomerulonephritis. Which of the following food choices by the parents indicates an understanding of the teaching?

Apples The nurse should instruct the parents that apples are low in sodium and supply the child with energy needed for recovery.

A nurse is caring for a 3-year-old female child who is prescribed an indwelling urinary catheter. Which of the following actions should the nurse take when performing this procedure?

Apply 2% lidocaine lubricant into the urethral meatus. The nurse should apply 2% lidocaine lubricant into the urethral meatus to assist in decreasing the discomfort the child might experience during catheterization.

A nurse is reinforcing teaching with the guardians of a school-age child who has frequent nosebleeds. Which of the following instructions should the nurse include?

Apply pressure to the child's nose. The nurse should instruct the guardians to apply pressure to the child's nose for at least 10 min to decrease bleeding. The nurse should also instruct the guardians to tilt the child's head forward, because this position prevents aspiration of the blood.

A nurse is preparing to administer ophthalmic drops to a child. Which of the following actions should the nurse take?

Apply pressure to the lacrimal punctum for 1 min following administration. The nurse should apply pressure to the lacrimal punctum to prevent the medication from entering the nasopharynx.

A nurse is preparing an adolescent for a lumbar puncture. Which of the following actions should the nurse take?

Apply topical analgesic cream to the site 1 hr prior to the procedure. The nurse should apply a topical analgesic to the lumbar site 1 hr prior to the procedure to decrease the adolescent's pain while the lumbar needle is inserted.

A nurse is preparing to administer furosemide to a toddler who has a heart defect. Which of the following actions should the nurse take to identify the toddler?

Ask the guardian to verify the child's name. Prior to administration of any medication, the nurse must correctly identify the toddler using two identifiers. The nurse should ask the guardian to verify the identity of the child and use the identification band as the second identifier.

A nurse is caring for a school-age child who in in Buck's traction following a leg fracture 24 hr ago. Which of the following actions should the nurse take?

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.

A nurse is caring for a toddler who has acute otitis media and a temperature of 40º C (104º F). After administering acetaminophen, which of the following actions should the nurse plan to take to reduce the toddler's temperature A. Apply a cooling blanket to the toddler. B. Dress the toddler in minimal clothing. C. Give the toddler a tepid bath. D. Administer diphenhydramine to the toddler.

B. Dress the toddler in minimal clothing

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

B. Give morphine 0.05mg/kg IV

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

B. I will give myself a shot of regular insulin 30 minutes before I eat breakfast

A nurse in an emergency department suspects that a toddler has epiglottitis. Which of the following actions should the nurse take A. Obtain a culture from the toddler's throat. B. Prepare the toddler for nasotracheal intubation. C. Visually inspect the epiglottis using a tongue depressor. D. Administer the Haemophilus influenzae type B conjugate vaccine.

B. Prepare the toddler for nasotracheal intubation: When epiglottitis is suspected the nurse should prepare for nasotracheal intubation or a tracheostomy, which might be required if the toddler begins to experience severe respiratory distress.

A nurse in an emergency department is caring for a school-age child who has sustained a superficial minor burn from fireworks on his forearm. Which of the following actions should the nurse take A. Administer a tetanus toxoid if more than 1 year since prior dose. B. Use an antimicrobial ointment on the affected area. C. Leave the burn area open to air. D. Place an ice pack on the affected area.

B. Use an antimicrobial ointment on the affected area

A nurse is assessing a school-age child who has appendicitis with possible perforation. The nurse should identify which of the following as a manifestation of peritonitis A. Hyperactive bowel sounds B. Abdominal distention C. Bradycardia D. Polyuria

B. abd distention

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 A. Prednisone B. Epinephrine C. Diphenhydramine D. Albuterol

B. 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.

A nurse is collecting data from a 12-month-old infant during a well-child visit. Which of the following findings should the nurse report to the provider?

BP 115/70 mm Hg The nurse should identify that this blood pressure is above the expected reference range for a 12-month-old infant and report this finding to the provider.

A nurse is reinforcing anticipatory guidance to the parents of an adolescent. Which of the following recommendations should the nurse include?

Be open to the adolescent's point of view. During this stage of development, adolescents are developing autonomy and self-identity. The nurse should recommend that the parents actively listen and be open to the adolescent's point of view, even if the parents disagree with his viewpoint.

A nurse is assisting with scoliosis screenings for a group of school-age children. The nurse should place the students in which of the following positions during the screening?

Bending forward with back parallel to the floor The nurse should observe for asymmetry and prominence of the rib cage by having the students bend forward with the back parallel to the floor.

A nurse is collecting data from a 12-month-old infant during a well-child visit. The nurse should identify which of the following findings as a deviation from expected growth and development?

Birth weight doubled The nurse should identify this finding as a deviation from expected growth and development. The infant's birth weight should triple by 12 months of age. Therefore, the nurse should report this finding to the provider.

A nurse is collecting data from an 18-month-old toddler who has just presented to the urgent care clinic. Which of the following data should the nurse investigate further?

Blood pressure 120/80 mm Hg A blood pressure of 120/80 mm Hg is outside the expected reference range for an 18-month-old toddler and requires further investigation by the nurse.

A nurse is collecting data from a school-aged child. The nurse should identify that which of the following findings is a manifestation of physical abuse?

Bruises at various stages of healing The nurse should recognize that bruises at various stages of healing are a clinical manifestation of physical abuse.

A nurse is assisting with the care for a 7-month-old infant who has a cleft palate. Which of the following actions should the nurse take to decrease the infant's risk for aspiration?

Burp the infant frequently during feedings. Infants with a cleft palate have difficulty creating a seal around a bottle. Burping the infant frequently, following every ounce of fluid consumed, dissipates swallowed air and helps to prevent aspiration.

A nurse is providing discharge teaching to the parent of a school-age child who has undergone a tonsillectomy. Which of the following statements by the parent should the nurse identify as understanding the teaching A. My child may resume usual activities since this was just an outpatient surgery." B. "My child will be able to drink the chocolate milkshake I promised to get for her tonight." C. "I will notify the doctor if I notice that my child is swallowing frequently." D. "I will have my child gargle with warm salt water to relieve her sore throat."

C. "I will notify the doctor if I notice that my child is swallowing frequently: The nurse should instruct the parent that frequent swallowing is a sign of bleeding and, if it is observed, to notify the primary care provider immediately.

A nurse is providing anticipatory guidance to the parents of an 8-month-old infant during a well-child visit. Which of the following statements should the nurse make A. Your baby should be able to stand while holding on to furniture." B. "Your baby should be able to say one to two words." C. Your baby should be able to sit unsupported." D. "Your baby should be able roll a ball to you."

C. "Your baby should be able to sit unsupported

A nurse is caring for a 2-week-old infant who is breastfeeding and requires a heel stick. Which of the following actions should the nurse take to minimize the infant's pain A. Instruct the mother not to breastfeed for 1 hr after the procedure. B. Undress the infant and place him under a radiant warmer prior to the procedure. C. Administer sucrose to the infant prior to the procedure. D. Recommend the mother avoid placing the infant in the kangaroo hold after the procedure.

C. Administer sucrose to the infant prior to the procedure

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

C. Cuts a shape using scissor

A nurse is assessing a school-age child who has an infratentorial brain tumor. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure? A. Hypotension B. Hyperactivity C. Decreased attention span D. Tachycardia

C. Decreased attention span

A charge nurse is preparing to make a room assignment for a newly admitted school-age child. Which of the following considerations is the nurse's priority when making a room assignment A. Length of stay B. Treatment schedule C. Disease process D. Self-care ability

C. Disease procesS

A school nurse is assessing a school-age child who has erythema infectiosum (fifth disease). Which of the following findings should the nurse expect A. Koplik spots B. Hoarseness C. Facial rash D. Splenomegaly

C. Facial rash: Erythema on the face, predominantly on the child's cheeks, is a manifestation of erythema infectiosum (fifth disease). The erythema causes the child to have the appearance of a "slapped face." The rash lasts from 1 to 4 days.

A nurse is assessing an 8-year-old child who has early indications of shock. After establishing an airway and stabilizing the child's respirations, which of the following actions should the nurse take next A. Insert an indwelling urinary catheter. B. Measure weight and height. C. Initiate IV access. D. Maintain ECG monitoring.

C. Initiate IV access

A nurse is caring for a newly-admitted school-age child who has hypopituitarism. Which of the following medications should the nurse expect the provider to recommend to the parents for treating the child's condition A. Desmopressin B. Luteinizing hormone-releasing hormone C. Recombinant growth hormone D. Levothyroxine

C. Recombinant growth hormone: Recombinant growth hormone injections are used to treat hypopituitarism, which inhibits cell growth and results in growth failure. The nurse should expect the provider to recommend this treatment to the child's parents. The nurse's role is to provide emotional support for the parents as they make a decision about the treatment they feel is best for their child.

A nurse is teaching a school-age child and his parent about postoperative care following cardiac catheterization. Which of the following instructions should the nurse include A. Stay home from school for 1 week following the procedure." B. Follow a diet that is low in fiber for 1 week." C. Wait 3 days before taking a tub bath." D. Apply a pressure dressing to the site for 3 days."

C. Wait 3 days before taking a tub bath: The child should keep the site clean and dry for at least 3 days to reduce the risk of infection. He should not take a tub bath for 3 days to avoid immersion of the incision in water.

A nurse is reviewing the lumbar puncture results of a school-age child suspected of having bacterial meningitis. Which of the following results should the nurse identify as a finding associated with bacterial meningitis Decreased cerebrospinal fluid pressure Decreased WBC count Increased protein concentration Increased glucose level

C. increased protein concentration: The nurse should recognize that an increased protein concentration in the spinal fluid is a finding associated with bacterial meningitis.

A nurse is assisting with the care of a child who is postoperative and received a transfusion during a surgical procedure. Which of the following findings indicates the child is having a hemolytic reaction?

Chills and flank pain Chills and flank pain are findings that indicate an incompatibility of the transfused blood product with the client's blood. The nurse should identify this finding as an indication that the child is having a hemolytic reaction.

A nurse is collecting data from a toddler who has gastroesophageal reflex disease (GERD). Which of the following findings should the nurse expect?

Chronic cough The nurse should identify that a chronic cough is an expected finding in a child who has GERD.

A nurse in the emergency department is caring for a toddler who has a partial thickness burns on their right arm. Which of the following actions should the nurse take?

Cleanse the affected area with mild soap and water. The nurse should wash the affected area with mild soap and water to remove any loose tissue that could cause infection.

A nurse is preparing to administer an enteral feeding to a child who has cerebral palsy and a nasogastric tube. Which of the following actions should the nurse take?

Confirm that the pH of the stomach contents is 5 or less. The nurse should test the pH of the stomach contents prior to administering the tube feeding in order to confirm tube placement in the stomach. The nurse should identify that a pH of 5 or less indicates gastric placement.

A nurse is reinforcing teaching with the parent of a 4-month-old infant who has a new prescription for nystatin to treat oral candidiasis and is breastfeeding. Which of the following instructions should the nurse include in the teaching?

Continue nystatin for 2 weeks after the symptoms disappear. To prevent relapse, nystatin therapy should continue for at least 2 weeks after the lesions disappear.

A nurse is caring for a toddler following a tonsillectomy. Which of the following is the priority finding that the nurse should report to the provider?

Continuous swallowing When using the urgent vs. nonurgent approach to client care, the nurse should identify that continuous swallowing is a manifestation of hemorrhage. Therefore, this is the priority finding for the nurse to report to the provider.

A nurse is assessing a 4-year-old child at a well-child visit. Which of the following developmental milestones should the nurse expect to observe?

Cuts an outlined shape using scissors. The nurse should recognize that an expected developmental milestone of a 4-year-old child is using scissors to cut out a shape.

A nurse is providing discharge teaching to the parents of a 6-month-old infant who is postoperative following hypospadias repair with a stent placement. Which of the following instructions should the nurse include in the teaching A. You may bathe your infant in an infant bathtub when you go home." B. Apply hydrocortisone cream to your infant's penis daily." C. "You should clamp your infant's stent twice daily." D. Allow the stent to drain directly into your infant's diaper."

D. "Allow the stent to drain directly into your infant's diaper: The nurse should instruct the parents to ensure that the stent drains directly into the infant's diaper to prevent kinking or twisting that can interfere with urine flow

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

D. "I will place my infant's diapers under the harness straps

A hospice nurse is caring for a preschooler who has a terminal illness. The father tells the nurse that he cannot cope anymore and has decided to move out of the house. Which of the following statements should the nurse make A. I think it is important that you provide emotional support for your family at this time." B. "I agree that you have to do what you feel is best for yourself during this stressful time." C. "You can't mean that; I'm sure you want to be there for your family." D. "Let's talk about some of the ways you have handled previous stressors in your life."

D. "Let's talk about some of the ways you have handled previous stressors in your life

A nurse is planning care for a preschooler who has cystic fibrosis. Which of the following interventions should the nurse include in the plan A. Administer pancreatic enzymes 2 hr after meals. B. Decrease pancreatic enzymes if steatorrhea develops. C. Limit fluid intake to 750 mL per day. D. Increase fat content in the child's diet to 40% of total calories.

D. Increase fat content in the child's diet to 40% of total calories :A child who has cystic fibrosis is unable to properly digest fats due to fibrosis of the pancreas and limited secretion of pancreatic enzymes. The nurse should increase the child's fat intake to equal 40% of total caloric intake.

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

D. Initiate droplet precautions for the child

A nurse is planning care for a school-age child who is in the oliguric phase of acute kidney injury (AKI) and has a sodium level of 129 mEq/L. Which of the following interventions should the nurse include in the plan A. Administer ibuprofen to the child for a temperature greater than 38º C (101º F). B. Assess the child's blood pressure every 8 hr. C. Weigh the child weekly at various times of the day. D. Initiate seizure precautions for the child.

D. 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 in order to maintain the child's safety.

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 A. Apple juice B. Peanut butter C. Chicken broth D. Oral rehydration solution

D. Oral rehydration solution

A community health nurse is assessing an 18-month-old toddler in a community day care. Which of the following findings should the nurse identify as a potential indication of physical neglect A. Resists having an axillary temperature taken B. Exhibits withdrawal behaviors when her parent leaves C. Has multiple bruises on her knees D. Poor personal hygiene

D. Poor personal hygiene

A nurse is preparing to suction an infant who has a tracheostomy. Which of the following actions should the nurse take A. Routinely suction every 30 min. B. Instill 0.9% sodium chloride prior to suctioning. C. Limit suctioning pressure to 40 mm Hg. D. Suction for 5 seconds or less.

D. Suction for 5 seconds or less

A nurse is planning care for a school-age child who has a tunneled central venous access device. Which of the following interventions should the nurse include in the plaN A. Use sterile scissors to remove the dressing from the site. B. Irrigate each lumen weekly with 10 mL of 0.9% sodium chloride solution when not in use. C. Access the site using a noncoring angled needle. D. Use a semipermeable transparent dressing to cover the site.

D. Use a semipermeable transparent dressing to cover the site

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

D. 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 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?

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.

A nurse is caring for an adolescent who has acne and a new prescription for isotretinoin. For which of the following adverse effects should the nurse monitor?

Depression Clients taking isotretinoin can experience mental status changes, such as suicidal thoughts, aggression, emotional lability, and depression. The nurse should monitor the adolescent's mental status while taking isotretinoin.

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

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

A nurse is assisting with the care of a 4-year-old child who is prescribed an IV medication preoperatively. Which of the following techniques should the nurse use to assist the child to cope with this procedure? (Select all that apply.)

Discuss the benefits of the procedure. The nurse should discuss the benefits of the procedure with the child, because this action is an age-appropriate activity that will decrease the child's anxiety about the procedure. It will also provide an opportunity for the nurse to clarify any misconceptions the child might have about the procedure. Give the child needleless IV supplies to play with. The nurse should allow the child to see, hold, and collect the supplies to familiarize the child with the potentially frightening aspects of the procedure, which will decrease the child's anxiety. Allow the child to perform the procedure with a doll. The nurse should allow the child to mimic the procedure with a doll to alleviate anxiety. It will also provide an opportunity for the nurse to clarify any misconceptions the child might have about the procedure.

A nurse is assisting with the admission of a toddler who has bacterial meningitis caused by Haemophilus influenzae type B. Which of the following isolation guidelines should the nurse plan to initiate?

Droplet precautions The nurse should plan to initiate droplet precautions for this child, because bacterial meningitis caused by Haemophilus influenzae type B is transmitted through the air via large-particle droplets.

A nurse is reinforcing teaching with the parent of a child who is being treated with diphenhydramine for allergic rhinitis. The nurse should tell the parent to monitor the child for which of the following?

Drowsiness Diphenhydramine can cause drowsiness due to CNS depression. The nurse should reinforce with the parent to administer the medication at bedtime to avoid daytime sedation.

A nurse in a pediatric clinic is collecting data from an infant who was recently exposed to pertussis. The nurse should recognize which of the following as a manifestation of pertussis?

Dry cough The nurse should identify that a dry cough is an early manifestation of pertussis.

A nurse in an urgent care clinic is assessing an adolescent who has an upper respiratory tract infection. Which of the following findings should the nurse identify as a manifestation of pertussis?

Dry, hacking cough The nurse should identify that a dry, hacking cough is a manifestation of pertussis. This disease usually begins with indications of an upper respiratory tract infection, which includes a dry, hacking cough that is sometimes more severe at night.

A nurse is reinforcing teaching about tracheostomy care with the parent of a toddler who has a temporary tracheostomy. Which of the following instructions should the nurse include in the teaching?

Ensure one finger fits between the ties and the neck. The nurse should instruct the parent that one finger should fit between the ties and the neck to ensure the tube is held securely in place.

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

Epinephrine This child is most likely experiencing an anaphylactic reaction to the cefazolin. According to evidence-based practice, the nurse should first administer epinephrine to treat the anaphylaxis. Epinephrine is a beta adrenergic agonist that stimulates the heart, causes vasoconstriction of blood vessels in the skin and mucous membranes, and triggers bronchodilation in the lungs.

A nurse is admitting a 4-month-old infant who has heart failure. Which of the following findings is the nurse's priority? (Click on the "Exhibit" button for additional information about the client. There are three tabs that contain separate categories of data EXHIBIT A. Episodes of vomiting B. Formula consumption C. Weight D. Temperature

Episodes of vomit: When using the urgent vs. nonurgent approach to client care, the nurse determines that the priority finding is three episodes of vomiting. This can indicate digoxin toxicity, which requires immediate intervention; therefore, this is the priority finding.

A nurse is discussing organ donation with the parents of a school-age child who has sustained brain death due to a bicycling accident. Which of the following actions should the nurse take first

Explore the parents' feelings and wishes regarding organ donation

A nurse is reinforcing teaching with the parents of a toddler who has strabismus. Which of the following treatments should the nurse plan to include in the teaching?

Eye patch Treatment of strabismus includes covering the strong eye to strengthen the muscles in the weak eye.

The nurse is caring for a preschooler who has been receiving IV fluids via a peripheral IV catheter. When preparing to discontinue the IV fluids and catheter, which of the following actions should the nurse plan to take?

First, the nurse should turn off the IV pump. Next, the nurse should occlude the IV tubing, and then remove the tape securing the catheter. Last, the nurse should apply pressure over the catheter insertion site.

A nurse is caring for a school-age child who is receiving a blood transfusion. Which of the following manifestations should alert the nurse to a possible hemolytic transfusion reaction?

Flank pain The nurse should recognize that flank pain is caused by the breakdown of RBCs and is an indication of a hemolytic reaction to the blood transfusion.

A nurse in an emergency department is caring for a school-age child who has appendicitis and rates their abdominal pain as 7 on a scale of 0 to 10. Which of the following actions should the nurse take?

Give morphine 0.05mg/kg IV A pain level of 7 on a scale of 0 to 10 is considered severe. The nurse should administer an analgesic medication for pain relief.

A nurse is preparing to leave the room after performing nasal suctioning for an infant who has respiratory syncytial virus (RSV). Identify the sequence in which the nurse should remove the following personal protective equipment (PPE).

Gloves Goggles Gown Mask The infant is on droplet and contact precautions due to the RSV. First, the nurse should remove his gloves, because these are the most contaminated. Second, the nurse should remove goggles, so they do not interfere with removing the other PPE. The nurse should then remove the gown, and finally the mask, to decrease exposure to the disease.

A nurse is caring for a child who has type 1 diabetes mellitus and has been receiving insulin via subcutaneous infusion pump. Which of the following laboratory tests would verify the average blood glucose level over the past 2 months?

Glycosylated hemoglobin Glycosylated hemoglobin provides an accurate average of the client's blood glucose level over the past 120 days. This test can be used to determine the effectiveness of, or compliance with, a treatment plan. It can also be used to diagnose diabetes mellitus.

A nurse is monitoring the oxygen saturation level of an infant using pulse oximetry. The nurse should secure the sensor to which of the following areas on the infant

Great toe: he nurse should secure the sensor to the great toe of the infant and then place a snug-fitting sock on the foot to hold the sensor in place. The nurse should also check the skin under the sensor site frequently for pulses, temperature, and color.

A nurse is collecting data from a child who has iron deficiency anemia. Which of the following data signifies that adherence to ferrous sulfate therapy has occured?

Green, tarry stools Green, tarry stools are an expected outcome of ferrous sulfate therapy. Therefore, this is an indication of adherence to the prescribed medication regimen.

A nurse is caring for an infant who has respiratory syncytial virus (RSV). Which of the following actions should the nurse implement for infection control?

Have a designated stethoscope in the infant's room. The nurse should initiate droplet precautions for an infant who has RSV because the virus is spread by direct contact with respiratory secretions. Therefore, designated equipment, such as a blood pressure cuff and a stethoscope, should be placed in the infant's room.

A nurse is assisting with the care of a child who has tonic-clonic seizures. Which of the following actions should the nurse take?

Have a suction canister and tubing available in the room. The nurse should have a suction canister and tubing available in the child's room to keep the child's airway patent during a seizure.

A nurse is preparing to obtain a peak expiratory flow rate from an adolescent. Which of the following actions should the nurse take?

Have the client stand during the procedure. To obtain the peak expiratory flow rate, the nurse should have the client stand during the procedure, which will allow the nurse to get an accurate reading.

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% The nurse should recognize that this hematocrit level is below the expected reference range of 32% to 44% for a school-age child. The child can exhibit fatigue, lightheadedness, tachycardia, dyspnea, and pallor due to the decreased oxygen-carrying capacity.

A nurse is reviewing the laboratory report of a 7 year-old child who is receiving chemotherapy. Which of the following lab values should the nurse report to the provider?

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.

A nurse is reviewing the laboratory values of a school-age child who has iron deficiency anemia. Which of the following findings should the nurse expect?

Hgb 9.0 g/dL The nurse should expect a child who has iron deficiency anemia to have an Hgb level below the expected reference range of 9.5 to 15.5 g/dL. An Hgb of 9.0 g/dL is below the expected reference range.

A nurse is assisting with the care of an infant who has spina bifida and recently had a ventriculoperitoneal shunt placed for hydrocephalus. Which of the following findings should the nurse identify as an indication of increased ICP?

High-pitched cry The nurse should identify that a high-pitched cry is an indication of increased intracranial pressure.

A nurse in a pediatric clinic is observing for an anaphylactic reaction after administering an IM antibiotic to a child 5 min ago. Which of the following manifestations should the nurse expect to observe first?

Hives The nurse should observe for hives first because this is an early manifestation of an anaphylactic reaction.

A nurse is collecting data about a 4-year-old preschooler's gross motor skills. The nurse should expect the preschooler to be able to perform which of the following activities?

Hopping on one foot The nurse should expect to find that a 4-year-old preschooler is able to hop on one foot.

A nurse is reviewing the medical record of a female adolescent client who has primary amenorrhea. Which of the following findings should the nurse identify as a risk factor for this disorder? (Select all that apply.)

Hypothyroidism The nurse should identify that hypothyroidism and other endocrine disorders are risk factors for primary amenorrhea. Cannabis use The nurse should identify that cannabis use is a risk factor for primary amenorrhea. Oral contraceptive use The nurse should identify that oral contraceptive use affects the estrogen and progesterone cycle and is a risk factor for primary amenorrhea. Emotional stress The nurse should identify that emotional stress causes hypothalamic suppression and is a risk factor for primary amenorrhea.

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?

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 lumbar puncture results of a school-age child suspected of having bacterial meningitis. Which of the following results should the nurse identify as a finding associated with bacterial meningitis?

Increased protein concentration The nurse should identify that an increased protein concentration in the spinal fluid is a finding that can indicate bacterial meningitis.

A nurse is administering an injection of epinephrine to a child who is experiencing manifestations of anaphylaxis. The nurse should monitor for which of the following adverse effects?

Increased systolic blood pressure Epinephrine is an adrenergic agonist used to treat anaphylaxis by activating the sympathetic nervous system. The nurse should expect the child to have an increased systolic blood pressure following administration of epinephrine.

A nurse is contributing to the plan of care for an adolescent client who has human immunodeficiency virus (HIV). Based on the adolescent's diagnosis, which of the following actions should be included in the plan of care?

Inform the client regarding routes of transmission. The nurse should inform the client about the transmission of HIV and how to prevent its spread.

A nurse is admitting a school-age child who has Pertussis. Which of the following actions should the nurse take?

Initiate droplet precautions for the child. The nurse should initiate droplet precautions for a child who has pertussis, also known as whooping cough. Pertussis is transmitted through contact with infected large-droplet nuclei that are suspended in the air when the child coughs, sneezes, or talks.

A nurse is planning care for a school-age child who is in the oliguric phase of acute kidney injury (AKI) and has a sodium level of 129 mEq/L. Which of the following interventions should the nurse include in the plan?

Initiate seizure precautions for the child. 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 reinforcing teaching with the guardian of a school-age child who has acute bacterial conjunctivitis and a new prescription for sulfacetaminde. Which of the following instructions should the nurse include?

Instill medication immediately after cleansing the eye. The nurse should instruct the guardian to place the medication in the eye immediately after cleansing.

A nurse is reinforcing teaching with the parent of a child who has hemophilia and is experiencing acute hemarthrosis. Which of the following instructions should the nurse include in the teaching?

Keep the affected joints immobilized The nurse should reinforce with the parent to keep the child's affected joints elevated and immobilized to minimize bleeding. After the acute episode, the child should begin active range-of-motion exercises.

A nurse is collecting data from a toddler at a well-child visit. Which of the following findings should the nurse identify as a possible indication of child maltreatment?

Laceration on the side of the torso A laceration on the side of the torso is not an injury that occurs due to the typical clumsiness of a toddler. This finding indicates the need to further investigate for suspected child maltreatment.

A nurse is reviewing the laboratory report of a preschooler. Which of the following laboratory results should the nurse report to the provider?

Lead 14 mcg/dL This lead level is above the expected reference range for a preschooler. Therefore, the nurse should report this result to the provider.

A nurse is assessing an infant who has a ventricular septal defect. Which of the following findings should the nurse expect?

Loud, harsh murmur The nurse should expect to hear a loud, harsh murmur with a ventricular septal defect due to the left-to-right shunting of blood, which contributes to hypertrophy of the infant's heart muscle.

A nurse is preparing to administer levabuterol via nebulizer to a child with asthma. Which of the following data should the nurse collect prior to administering the medication?

Lung sounds Levalbuterol is a bronchodilator used to increase air exchange. The nurse should evaluate lung sounds prior to and after the administration of the medication to determine changes in respiratory status.

A nurse is assisting with the care of a 3-year-old child who is prescribed a lumbar puncture. Which of the following actions should the nurse take to prevent complications?

Maintain the child in a flat position after the procedure. After a lumbar puncture, the optimal position for the client is flat and supine to prevent headaches.

A nurse is caring for a school-age child who has acute rheumatic fever. Which of the following actions should the nurse take

Maintain the child on bed rest

A nurse is contributing to the plan of care for a child who is in Buck's traction. Which of the following interventions should the nurse include in the plan?

Maintain the leg in an extended position. The nurse should have the child maintain her affected leg in an extended position while in Buck's traction. This position decreases the risk for further injury to the extremity and minimizes the occurrence of muscle spasms.

A nurse is preparing to assist a provider with a lumbar puncture for a school-aged child. Which of the following actions is the nurse's priority?

Maintaining the child's position The greatest risk to the child is injury to the spinal nerves or the major vessels. Therefore, the priority action is for the nurse to maintain the child's position to prevent trauma.

A nurse is caring for a 15 year-old client following a head injury. Which of the following findings should the nurse identify as an indication that the child is developing syndrome of inappropriate antidiuretic hormone secretion (SIADH)?

Mental confusion A child who has a head injury can develop SIADH as a result of altered pituitary function, leading to an oversecretion of antidiuretic hormone. Oversecretion of antidiuretic hormone leads to a decrease in urine output, hyponatremia, and hypoosmolality due to overhydration. As the hyponatremia becomes more severe, mental confusion and other neurologic manifestations such as seizures can occur.

A nurse is preparing a toddler for suturing of a minor facial laceration. The nurse should place the toddler in which of the following restraints?

Mummy restraint The nurse should use a mummy wrap when a short-term restraint is needed for treatment of the toddler that involves the head and neck. The nurse should always use the least amount of restraint necessary.

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?

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 reinforcing teaching with the parent of a child who has a new prescription for ferrous sulfate. The nurse should reinforce that the parent should administer the medication with which of the following fluids to enhance the medication absorption?

Orange juice The nurse should reinforce with the parent that administering ferrous sulfate with orange juice will enhance medication absorption.

A nurse is preparing to collect a sample from a toddler for a sickle-turbidity test. Which of the following actions should the nurse plan to take?

Perform a finger stick. The nurse should perform a finger stick on a toddler as a component of the sickle-turbidity test. If the test is positive, hemoglobin electrophoresis is required to distinguish between children who have the genetic trait and children who have the disease.

A nurse is assessing a school-age child who has meningitis. Which of the following findings is the priority for the nurse to report to the provider?

Petechiae on the lower extremities The presence of a petechial or purpuric rash on a child who is ill can indicate the presence of meningococcemia. This type of rash indicates the greatest risk of serious rapid complications from sepsis and should be reported immediately to the provider.

A nurse is caring for a school-age child who has experienced a tonic-clonic seizure. Which of the following actions should the nurse take during the immediate postictal period?

Place the child in a side-lying position. The nurse should place the child in a side-lying position to prevent aspiration.

A nurse is assisting with the administration of a nasogastric enteral feeding for an infant. Which of the following actions should the nurse take?

Place the infant in semi-Fowler's position for 1 hr after the feeding. The nurse should elevate the head of the infant's bed by 30º to 45º for 30 min to 1 hr after the feeding.

A nurse is contributing to the plan of care for a 10-month-old infant who is postoperative following a cleft palate repair. Which of the following actions should the nurse include in the plan of care?

Place the infant in side-lying position. The nurse should place the infant in side-lying position to promote healing and prevent injury to the surgical site.

A nurse is reviewing the laboratory report of a preschooler who has a Wilm's tumor and is scheduled to begin treatment with an antineoplastic medication regimen. Which of the following laboratory results should the nurse report to the provider?

Platelet count 70,000/mm3 This platelet count is below the expected reference range for a preschooler and increases the risk for spontaneous bleeding. The nurse should hold the medication and report this finding to the provider immediately.

A nurse is providing teaching about social development to the parents of a preschooler. Which of the following play activities should the nurse recommend for the child?

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 1-month-old infant who has a nasogastric tube in place for intermittent feedings. Which of the following actions should the nurse take?

Position the head of the crib at a 30° angle between feedings. The nurse should place the infant with the head of the crib elevated 30° to 45° to prevent aspiration.

A nurse is contributing to the plan of care for a child who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following is the priority intervention for the nurse to recommend to include in the plan?

Promote oxygen utilization The priority action the nurse should take when using the airway, breathing, circulation (ABC) approach to client care is promoting oxygen utilization to prevent further sickling of the red blood cells and promote adequate oxygenation of the tissue.

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. The metabolic rate of a child who has heart failure is high because of poor cardiac function. Therefore, the nurse should provide small, frequent meals for the child because it helps to conserve energy.

A nurse is 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 to the child

During a well-child visit, the parent of a toddler expresses concern to the nurse that the toddler takes several hours to fall asleep at night. Which of the following recommendations should the nurse make?

Provide the toddler with a favorite toy at bedtime. The nurse should recommend to the parent that providing the toddler with a favorite toy at bedtime will help the toddler to feel more secure and facilitate sleep.

A nurse is reinforcing teaching with the parents of a 2-year-old toddler at a well-child visit. Which of the following should the nurse recommend as an age-appropriate activity for the toddler?

Putting together a large-piece puzzle The nurse should recommend putting together a large-piece puzzle as an age-appropriate activity for a 2-year-old toddler. Puzzles provide the child an opportunity to develop fine motor skills. Other fine motor skill activities include finger painting and coloring with thick crayons.

A nurse is caring for a school-age child who has skeletal traction applied to the right lower leg to repair a femur fracture. Which of the following findings is the priority for the nurse to report to the provider?

Report of tingling in the right foot The nurse should identify that the greatest risk to the child is nerve injury. Therefore, tingling in the right foot, which can indicate nerve damage or compartment syndrome, is the priority finding for the nurse to report to the provider.

A nurse is assessing a 3-year-old toddler at a well-child visit. Which of the following manifestations should the nurse report to the provider?

Respiratory rate 45/min The nurse should identify that a respiratory rate of 45/min is above the expected reference range of 20 to 25/min for a 3-year-old toddler and can indicate respiratory dysfunction and acute respiratory distress. Therefore, the nurse should report this finding to the provider.

A nurse is providing discharge teaching to the parents of a Caucasian toddler who had a lower leg cast applied 24 hr ago. The nurse should instruct the parents to report which of the following findings to the provider

Restricted ability to move the toe

A nurse is planning care for a toddler who has a serum lead level of 4 mcg/dL. Which of the following actions should the nurse plan to take?

Schedule the toddler for a yearly rescreening. The nurse should schedule the toddler for a lead level rescreening in 1 year and educate the family on ways to prevent exposure.

A nurse is caring for a school-age child who is receiving chemotherapy and is severely immunocompromised. Which of the following actions should the nurse take

Screen the child's visitors for indications of infection

A nurse is caring for a school-age child who is receiving chemotherapy and is severely immunocompromised. Which of the following actions should the nurse take?

Screen the child's visitors for indications of infection. 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.

A nurse is reinforcing teaching with the parents of preschoolers regarding the use of booster seats in a motor vehicle. Which of the following instructions should the nurse include in the teaching?

Secure the child in the booster seat using the motor vehicle's shoulder-lap seat belt. The nurse should instruct the parents to secure both the child and the booster seat with the shoulder-lap seat belt inside the motor vehicle, because booster seats do not have built-in straps.

A nurse is caring for an adolescent who received a kidney transplant. Which of the following findings should the nurse identify as an indication the adolescent is rejecting the kidney?

Serum creatinine 3.0 mg/dL Creatinine is a byproduct of protein metabolism and is excreted from the body through the kidneys. An elevated serum creatinine level, therefore, can be an indication that the kidneys are not functioning. The nurse should identify that the adolescent's serum creatinine level is higher than the expected reference range of 0.4 to 1.0 mg/dL for an adolescent and can indicate rejection of the kidney.

A nurse is caring for an adolescent who received a kidney transplant. Which of the following findings should the nurse identify as an indication the adolescent is rejecting the kidney

Serum creatinine 3.0 mg/dt: 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 normal reference range and may indicate rejection of the kidney.

A nurse is auscultating heart sounds on an infant. The nurse should identify this sound as which of the following? (Audio clip)

Sinus rhythm The nurse should identify this heart sound as sinus rhythm. The nurse should auscultate heart sounds at the apical impulse, which is at the left midclavicular line and fifth intercostal space. The expected heart sounds include S1, which is the closure of the atrioventricular valves, and S2, which is the closure of the semilunar valves.

A nurse is collecting data from a 10-month-old infant. Which of the following findings should the nurse report to the provider?

Sits with support by leaning on hands The nurse should identify that sitting with support can indicate a developmental delay, because an infant should be able to sit unsupported by 8 months of age. Therefore, the nurse should report this finding to the provider.

A nurse is reviewing the laboratory report of an infant who is receiving treatment for severe dehydration. The nurse should identify that which of the following laboratory values indicates effectiveness of the current treatment?

Sodium 140 mEq/L The nurse should identify that a sodium level of 140 mEq/L is within the expected reference range of 134 to 150 mEq/L and indicates the current treatment regimen the infant is receiving for dehydration is effective.

A nurse is reviewing the laboratory report of a school-age child who is receiving prednisone. Which of the following laboratory results should the nurse report to the provider?

Sodium 150 mEq/L Hypernatremia is an adverse effect of prednisone. This level is above the expected reference range for a school-age child. Therefore, the nurse should report this value to the provider.

A nurse is reinforcing teaching with the guardians of a school-age child who has hearing loss. Which of the following techniques should the nurse recommend to facilitate communication with the child?

Speak at the child's eye level. The nurse should instruct the guardian to speak at the child's eye level and ensure that there is adequate lighting on the speaker's face to facilitate lipreading and communication.

The nurse is providing discharge teaching to the parent of a child who is 1 week postoperative following a cleft palate repair. For which of the following members of the inter professional team should the nurse initiate a referral?

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.

A nurse is reinforcing teaching with the parents of a 7-year-old female child about behavioral expectations. Which of the following behaviors should the nurse include in the teaching?

Spends a lot of time by herself Spending time alone is an expected characteristic of a 7-year-old female child. When they do spend time with others, children in this age group prefer to socialize with children of the same sex and age.

A nurse is assisting the provider with a developmental assessment of a toddler. Which of the following behaviors should the nurse recognize as an expected finding?

Stands on one foot for several seconds Standing on one foot for several seconds is an expected behavior for a toddler.

A nurse in an emergency department is performing an admission assessment on a 2 week-old male newborn. Which of the following findings is the priority for the nurse to report to the provider?

Substernal retractions When using the airway, breathing, and circulation approach to client care, the nurse should determine that the priority finding to report to the provider is substernal retractions. This finding indicates the newborn is experiencing increased respiratory effort, which could quickly progress to respiratory failure.

A charge nurse in an emergency department is preparing an in-service for a group of newly licensed nurses on the clinical manifestations of child maltreatment. Which of the following manifestations should the charge nurse include as suggestive of potential physical abuse?

Symmetric burns of the lower extremities The nurse should include that symmetric burns to the lower extremities can indicate physical abuse. The patterns are usually characteristic of the method or object used, such as cigar or cigarette burns, or burns in the shape of an iron.

A nurse is auscultating the lungs of an adolescent who has asthma. The nurse should identify the sound as which of the following?

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.

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

Tachypnea 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 assessing the vital signs of a 10-year-old child following a burn injury. The nurse should identify that which of the following findings in an indication of early septic shock?

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.

A nurse in a clinic is collecting data from an adolescent who has received all recommended immunizations through the age of 6 years. Which of the following immunizations should the nurse plan to administer?

Tetanus, diphtheria toxoids, and acellular pertussis (Tdap) The Tdap vaccine is recommended between the ages of 11 and 12 years. Therefore, this adolescent should receive the Tdap vaccine now.

A nurse is collecting data from a child during a well-child visit. The nurse should recognize that which of the following findings places the child at a higher risk for abuse?

The child was born at 30 weeks of gestation. The nurse should identify that children who are born prematurely are at greater risk for abuse because of the potential for impaired bonding during early infancy.

A nurse is reviewing the plan of care for a child who has cystic fibrosis. Which of the following is the priority goal for this child?

The child will maintain an effective breathing pattern. Manifestations of cystic fibrosis, such as chronic cough, pulmonary infection, and bronchiolar obstruction lead to severely impaired ventilation and gas exchange, which causes long-term pulmonary complications. Therefore, when utilizing the airway, breathing, circulation approach to client care, maintaining an effective breathing pattern is the priority goal for the child who has cystic fibrosis.

A nurse is collecting physical data from a 4-year-old child who has diarrhea and has been vomiting for 24 hr. Which of the following sites should the nurse grasp to determine the child's skin turgor?

The child's abdomen. The nurse should expect the child who has diarrhea and has been vomiting to exhibit manifestations of dehydration, such as a decrease in skin turgor. To check skin turgor, the nurse should grasp the skin on the child's abdomen, pull it taut, and release it quickly. The child who is dehydrated will have a prolonged period of tenting.

A nurse is collecting data about the dietary habits of an adolescent client. The nurse should identify that which of the following findings puts the client at risk for nutritional deficits?

The client skips eating dinner for track practice three times per week. The nurse should identify that adolescents are often at risk for developing poor eating habits. Skipping dinner twice each week puts this client at risk for nutritional deficits.

A nurse is collecting data from a 12-month-old infant during a well-child visit. At birth, the infant's weight was 3.6 kg (8 lb) and his length was 50.8 cm (20 in). Based on this data, which of the following findings should the nurse expect?

The infant is 76.2 cm (30 in) long The nurse should expect a length of 76.2 cm (30 in), because the infant's length should increase by about 50% by 12 months of age.

A nurse is assisting with the development of a health promotion program for the guardians of adolescents. Which of the following information about adolescents should the nurse recommend to include in the program?

The leading cause of death in adolescents is physical injury. The nurse should recommend including this information, because injuries from motor-vehicle crashes are the leading cause of death in the adolescent population.

A nurse is collecting data from a 6-month-old child who is experiencing a sickle cell crisis. Which of the following areas should the nurse observe when monitoring for manifestations of splenic sequestration?

The nurse should observe the location over the infant's spleen (LUQ of abdomen) when monitoring for manifestations of splenic sequestration. Splenic sequestration is an enlargement of the spleen due to pooling of sickled cells in the blood.

A nurse is collecting data from an 18-month-old toddler. Which of the following is a deviation from expected growth and development that the nurse should report to the provider?

The toddler is unable to recognize familiar objects by name. The nurse should report that the toddler is unable to recognize familiar objects by name, because this is a deviation from expected growth and development. The toddler should be able to accomplish this task by 12 months of age.

The nurse is interviewing the parent of an 18-month-old toddler during a well-child visit. The nurse should identify that which of the following findings indicates a need to assess the toddler for hearing loss?

The toddler received tobramycin during a hospitalization 2 weeks ago. 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 interviewing the parent of an 18-month-old toddler during a well-child visit. The nurse should identify that which of the following findings indicates a need to assess the toddler for hearing loss

The toddler received tobramycin during a hospitalization 2 weeks ago: 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 preparing to administer a hep B vaccine to a 1-month-old. The nurse should plan to inject the medication at which location?

Thigh

A nurse is reinforcing teaching with the guardian of a child who has a new diagnosis of enterobiasis. The nurse should advise the guardian to take which of the following actions to prevent infection?

Trim the child's fingernails short. The nurse should instruct the guardian to trim the child's fingernails short to reduce the collection of eggs under her nails and prevent reinfection.

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

Urticaria The nurse should monitor the child for an allergic reaction to the contrast dye. Manifestations of the allergic reaction include urticaria, itching, flushing of the skin, and possible anaphylaxis.

A nurse is teaching a school-age child who has a severe allergy to bee venom and his parent about epinephrine. Which of the following instructions should the nurse include in the teaching

Use a second dose if the first dose of epinephrine does not completely reverse the symptom: A biphasic response, in which the child will appear to recover and then experience a recurrence of symptoms, is possible with some allergic reactions. The nurse should instruct the parent and child to use a second dose if the first dose does not resolve all the symptoms.

A nurse is preparing to administer an IM injection to an 11-month-old infant. In which of the following areas should the nurse administer the injection?

Vastus lateralis The nurse should administer an IM injection in the vastus lateralis muscle of an 11-month-old infant. The vastus lateralis is a well-developed muscle that is safe to use for infants and small children.

A nurse is reinforcing teaching with the parent of a school-age child who has lactose intolerance. Which of the following supplements should the nurse instruct the parent to include in the child's diet?

Vitamin D Lactose intolerance is managed by eliminating dairy products from the diet. However, this can result in a decrease in bone density because of the lack of calcium and vitamin D in the diet. The nurse should instruct the parent to administer a vitamin D supplement to the child to enhance the absorption of calcium from foods other than those containing lactose.

A nurse in a pediatric clinic is collecting data from an infant who recently started taking digoxin. Which of the following manifestations should the nurse identify as an indication of digoxin toxicity and report to the provider?

Vomiting The nurse should identify that vomiting, especially unrelated to feedings, is a manifestation of digoxin toxicity and should be reported to the provider.

A nurse is reinforcing discharge teaching with the guardians of a 6-month-old infant following a surgical procedure to repair a hypospadias. Which of the following instructions should the nurse include?

Wait 1 week before giving the infant a tub bath. The nurse should instruct the guardians to keep the infant's penis as dry as possible until the stent or catheter is removed. The parent should provide sponge-baths to the child until the stent or catheter is removed.

A nurse is collecting data from an infant who has severe dehydration. Which of the following findings should the nurse expect?

Weight loss of 10% The nurse should expect an infant who has severe dehydration to experience weight loss of 10% or greater.

A nurse is proving 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?

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 reinforcing dietary teaching with the guardian of a school-age child who has celiac disease. Which of the following foods should the nurse recommend including in the child's diet?

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

A nurse in a provider's office if preparing to administer immunizations to a toddler during a well-child visit. Which of the following actions should the nurse plan to take?

Withhold the measles, mumps, and rubella (MMR) vaccine. The nurse should recognize that an allergy to neomycin with an anaphylactic reaction is a contraindication for receiving the MMR vaccine. Clients who have a severe allergy to eggs or gelatin should not receive this vaccine.

A nurse is reinforcing teaching with the family of an adolescent client who was recently diagnosed with celiac disease. Which of the following foods should the nurse recommend?

Yellow corn A client who has celiac disease is unable to process gluten, a protein found in wheat, barley, rye, and oats. The nurse should instruct the family that the client's diet is restricted to foods that are free of gluten, such as corn, rice, and millet.

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 Diaper dermatitis is a common inflammatory skin disorder caused by contact with an irritant such as urine, feces, soap, or friction, and takes the form of scaling, blisters, or papules with erythema. Providing a protective barrier, such as zinc oxide, against the irritants allows the skin to heal.

A nurse is caring for a school-age child who is receiving a blood transfusion. Which of the following manifestations should alert the nurse to a possible hemolytic transfusion reaction

flank pain

A nurse is assessing a toddler who has gastroenteritis and is exhibiting manifestations of dehydration. Which of the following findings should the nurse address first

tachypnea: When using the airway, breathing, circulation approach to client care, the first finding the nurse should address is the toddler's tachypnea, which results when the kidneys are unable to excrete hydrogen ions and produce bicarbonate leading to metabolic acidosis.

A nurse is admitting an infant who has intussusception. Which of the following findings should the nurse expect? (Select all that apply) Steatorrhea Vomiting Lethargy Constipation Weight gain

vomiting, lethargy: Steatorrhea is incorrect. The nurse should expect the infant with intussusception to have bloody stools that are currant jelly-like in appearance. Steatorrhea is bulky, fatty stools, and is a manifestation of cystic fibrosis. Vomiting is correct. The nurse should expect the infant with intussusception to exhibit vomiting due to the obstruction that occurs when a segment of the bowel telescopes within another segment of the bowel. Lethargy is correct. The nurse should expect the infant with intussusception to exhibit lethargy due to episodes of severe pain during which the infant cries inconsolably leading to exhaustion and decreased nutritional intake. Constipation is incorrect. The nurse should expect the infant with intussusception to have mucus-filled and currant jelly-like diarrhea due to the leaking of blood and mucus into the intestinal lumen. Weight gain is incorrect. The nurse should expect the infant with intussusception to have weight loss due to anorexia and episodes of vomiting and diarrhea.