fundamentals exam 4

Antibiotics are prescribed for a child with otitis media who underwent a myringotomy with insertion of tympanostomy tubes. The nurse provides discharge instructions to the parents regarding the administration of the antibiotics. Which statement, if made by the parents, indicates understanding of the instructions provided?

"Administer the antibiotics until they are gone."

The mother of a hospitalized 2-year-old child with viral laryngotracheobronchitis (croup) asks the nurse why the pediatrician did not prescribe antibiotics. Which response should the nurse make?

"Antibiotics are not indicated unless a bacterial infection is present."

The nurse prepares a teaching plan for the mother of a child diagnosed with bacterial conjunctivitis. Which, if stated by the mother, indicates a need for further teaching?

"It is okay to share towels and washcloths."

The clinic nurse is providing instructions to a parent of a child with cystic fibrosis regarding the immunization schedule for the child. Which statement should the nurse make to the parent?

"The child will receive the recommended basic series of immunizations along with a yearly influenza vaccination."

A new parent expresses concern to the nurse regarding sudden infant death syndrome (SIDS). She asks the nurse how to position her new infant for sleep. In which position should the nurse tell the parent to place the infant?

Back rather than on the stomach

The nurse is preparing to care for a child with a diagnosis of intussusception. The nurse reviews the child's record and expects to note which sign of this disorder documented?

Bright red blood and mucus in the stools

A child has fluid volume deficit. The nurse performs an assessment and determines that the child is improving and the deficit is resolving if which finding is noted?

Capillary refill is less than 2 seconds.

A nurse is preparing a presentation about basic nutrients for a group of high school athletes. She should explain that which of the following nutrients provides the body with the most energy?

Carbohydrates.

A client who has an indwelling catheter reports a need to urinate. Which of the following actions should the nurse take?

Check to see whether the catheter is patent.

A pediatrician prescribes an intravenous (IV) solution of 5% dextrose and half-normal saline (0.45%) with 40 mEq of potassium chloride for a child with hypotonic dehydration. The nurse performs which priority assessment before administering this IV prescription?

Checks the amount of urine output

The nurse reviews the record of a newborn infant and notes that a diagnosis of esophageal atresia with tracheoesophageal fistula is suspected. The nurse expects to note which most likely sign of this condition documented in the record?

Choking with feedings

While a nurse is administering a cleansing enema, the client reports abdominal cramping. Which of the following actions should the nurse take?

Clamp the enema tubing

A nurse is teaching a client who reports stress urinary incontinence. Which of the following instructions should the nurse include? (Select all that apply.)

Decrease or avoid caffeine. Avoid drinking alcohol.

A 10-year-old child with asthma is treated for acute exacerbation in the emergency department. The nurse caring for the child should monitor for which sign, knowing that it indicates a worsening of the condition?

Decreased Wheezing

A nurse is caring for a client who has a prescription for a 24-hr urine collection. Which of the following actions should the nurse take?

Discard the first voiding.

A school-age child with type 1 diabetes mellitus has soccer practice and the school nurse provides instructions regarding how to prevent hypoglycemia during practice. Which should the school nurse tell the child to do?

Eat a small box of raisins or drink a cup of orange juice before soccer practice.

The mother of a 6-year-old child who has type 1 diabetes mellitus calls a clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the child's urine and it was positive for ketones. The nurse should instruct the mother to take which action?

Encourage the child to drink liquids.

The mother of an 8-year-old child being treated for right lower lobe pneumonia at home calls the clinic nurse. The mother tells the nurse that the child complains of discomfort on the right side and that ibuprofen is not effective. Which instruction should the nurse provide to the mother?

Encourage the child to lie on the right side.

The nurse is caring for a newborn with a suspected diagnosis of imperforate anus. The nurse monitors the infant, knowing that which is a clinical manifestation associated with this disorder?

Failure to pass meconium stool in the first 24 hours after birth

The clinic nurse reviews the record of an infant and notes that the primary health care provider (PHCP) has documented a diagnosis of suspected Hirschsprung's disease. The nurse reviews the assessment findings documented in the record, knowing that which sign most likely led the mother to seek health care for the infant?

Foul-smelling ribbon-like stools

The nurse is caring for a child after a tonsillectomy. The nurse monitors the child, knowing that which finding indicates the child is bleeding?

Frequent Swallowing

A nurse is reviewing factors that increase the risk of urinary tract infections (UTs) with a client who has recurrent UTIs. Which of the following factors should the nurse include? (Select all that apply.)

Frequent sexual intercourse Location of the urethra closer to the anus Frequent catheterization

An adolescent client with type 1 diabetes mellitus is admitted to the emergency department for treatment of diabetic ketoacidosis. Which assessment findings should the nurse expect to note?

Fruity breath odor and decreasing level of consciousness

The nurse should implement which interventions for a child older than 2 years with type 1 diabetes mellitus who has a blood glucose level of 60 mg/dL (3.4 mmol/L)? Select all that apply.

Give the child a teaspoon of honey. Prepare to administer glucagon subcutaneously if unconsciousness occurs.

A nurse is preparing to initiate a bladder-retraining program for a client who has incontinence. Which of the following actions should the nurse take? (Select all that apply.)

Have the client record urination times. Gradually increase the urination intervals. Remind the client to hold urine until the next scheduled urination time.

A nurse is assessing a client who has had diarrhea for 4 days. Which of the following findings should the nurse expect? (Select all that apply.)

Hypotension Elevated temperature Poor skin turgor

A nurse is caring for a client who is at highrisk for aspiration. Which of the followingactions should the nurse take?

Instruct the client to tuck their chin when swallowing.

A mother brings her 2-week-old infant to a clinic for a phenylketonuria rescreening blood test. The test indicates a serum phenylalanine level of 1 mg/dL (60.5 mcmol/L). The nurse reviews this result and makes which interpretation?

It is negative.

An infant has just returned to the nursing unit after surgical repair of a cleft lip on the right side. The nurse should place the infant in which best position at this time?

Left lateral position

A child with laryngotracheobronchitis (croup) is placed in a cool mist tent. The mother becomes concerned because the child is frightened, consistently crying, and trying to climb out of the tent. Which is the most appropriate nursing action?

Let the mother hold the child and direct the cool mist over the child's face.

A child has been diagnosed with acute otitis media of the right ear. Which interventions should the nurse include in the plan of care? Select all that apply.

Provide a soft diet. Administer ibuprofen for fever every 4 hours as prescribed and as needed. Instruct the parents about the need to administer the prescribed antibiotics for the full course of therapy.

A child is hospitalized because of persistent vomiting. The nurse should monitor the child closely for which problem?

Metabolic alkalosis

The nurse is caring for an infant with bronchiolitis, and diagnostic tests have confirmed respiratory syncytial virus (RSV). On the basis of this finding, which is the most appropriate nursing action?

Move the infant to a private room.

A child with type 1 diabetes mellitus is brought to the emergency department by the mother, who states that the child has been complaining of abdominal pain and has been lethargic. Diabetic ketoacidosis is diagnosed. Anticipating the plan of care, the nurse prepares to administer which type of intravenous (IV) infusion?

Normal saline infusion

A nurse in a senior center is counseling a group of older adults about their nutritional needs and considerations. Which of the following information should the nurse include? (Select all that apply.)

Older adults are more prone to dehydration than younger adults are. Older adults need the same amount of most vitamins and minerals as younger adults do. Many older men and women need calcium supplementation.

A nurse is providing dietary teaching for a client who reports constipation. Which of the following foods should the nurse recommend?

One medium apple with skin

The nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by respiratory syncytial virus (RSV). Which interventions should the nurse include in the plan of care? Select all that apply.

Place the infant in a private room. Wear a mask, gown, and gloves when in contact with the infant. Ensure that nurses caring for the infant with RSV do not care for other high-risk children.

The clinic nurse reads the results of a tuberculin skin test (TST) on a 3-year-old child. The results indicate an area of induration measuring 10 mm. The nurse should interpret these results as which finding?

Positive

The mother of a 6-year-old child arrives at a clinic because the child has been experiencing itchy, red, and swollen eyes. The nurse notes a discharge from the eyes and sends a culture to the laboratory for analysis. Chlamydial conjunctivitis is diagnosed. On the basis of this diagnosis, the nurse determines that which requires further investigation?

Possible sexual abuse

The nurse admits a child to the hospital with a diagnosis of pyloric stenosis. On assessment, which data would the nurse expect to obtain when asking the parent about the child's symptoms?

Projectile vomiting

The nurse is reviewing the laboratory results for a child scheduled for a tonsillectomy. The nurse determines that which laboratory value is most significant to review?

Prothrombin time

Which interventions should the nurse include when creating a care plan for a child with hepatitis? Select all that apply.

Providing a low-fat, well-balanced diet. Teaching the child effective hand-washing techniques. Instructing the parents to avoid administering medications unless prescribed.

The nurse has just administered ibuprofen to a child with a temperature of 102° F (38.8° C). The nurse should also take which action?

Remove excess clothing and blankets from the child.

The nurse provides home care instructions to the parents of a child with celiac disease. The nurse should teach the parents to include which food item in the child's diet?

Rice

The nurse is preparing to care for a child after a tonsillectomy. The nurse documents on the plan of care to place the child in which position?

Side-lying

After a tonsillectomy, the nurse reviews the surgeon's postoperative prescriptions. Which prescription should the nurse question?

Suction every 2 hours.

The day care nurse is observing a 2-year-old child and suspects that the child may have strabismus. Which observation made by the nurse indicates the presence of this condition?

The child consistently tilts the head to see.

The emergency department nurse is caring for a child diagnosed with epiglottitis. In assessing the child, the nurse should monitor for which indication that the child may be experiencing airway obstruction?

The child is leaning forward, with the chin thrust out.

A nurse is caring for a client who will perform fecal occult blood testing at home. Which of the following information should be included when explaining the procedure to the client?

The specimen cannot be contaminated with urine.

The nurse provides feeding instructions to a parent of an infant diagnosed with gastroesophageal reflux disease. Which instruction should the nurse give to the parent to assist in reducing the episodes of emesis?

Thicken the feedings by adding rice cereal to the formula.

After a tonsillectomy, a child begins to vomit bright red blood. The nurse should take which initial action?

Turn the child to the side.

A nurse is caring for a client who requires a low-residue diet. The nurse should expect to see which of the following foods on the client's meal tray?

Vanilla custard

A nurse is preparing to administer a cleansing enema to an adult client in preparation for a diagnostic procedure. Which of the following steps should the nurse take? (Select all that apply.)

Warm the enema solution prior to instillation. Position the client on the left side with the right leg flexed forward. Lubricate the rectal tube or nozzle.