HPA III exam 3 ATI

A. "It is expected for children who are hospitalized to regress. The toileting skills will return when your child is feeling better." Rationale:A recently learned skill, such as toilet training, is often temporarily lost due to the stress of hospitalization. The nurse should reassure the parents that regression is an expected behavior in children who are hospitalized and that her child will regain bladder control when she is feeling better.

.A nurse is caring for a 4-year-old child who has croup and wet the bed overnight. When the parents visit the next day, the nurse explains the situation and one of the parents says, "She never wets the bed at home. I am so embarrassed." Which of the following responses should the nurse make? A. "It is expected for children who are hospitalized to regress. The toileting skills will return when your child is feeling better." B. "I know this can really be embarrassing. I have kids myself, so I understand, and it doesn't bother me." C. "Your child did not seem upset, so I wouldn't worry about it if I were you." D. "Why does it bother you that your child has wet the bed?"

C. Drink 48 to 64 ounces of water daily. Rationale: The client who has preeclampsia is encouraged to drink six to eight 8-ounce glasses of water (48 to 64 ounces) per day. She should avoid alcohol and limit intake of caffeinated beverages

.A nurse is completing discharge teaching to a client in her 35th week of pregnancy who has mild preeclampsia. Which of the following information about nutrition should be included in the teaching? A. Consume 40 to 50 g of protein daily. B. Avoid salting of foods during cooking. C. Drink 48 to 64 ounces of water daily. D. Limit intake of whole grains, raw fruits, and vegetables.

13 gtt/min

A nurse is preparing to administer 0.9% sodium chloride 1,200 mL IV to infuse over 24 hr. The drop factor of the manual IV tubing is 15 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) ______ gtt/min

Do not palpate abdomen. Rationale: Wilms' tumor is a neoplasm of the kidney (nephroblastoma). This tumor is encapsulated, and palpation can cause it to rupture, which would allow seeding of the tumor into the pelvic cavity.

A child is admitted with a suspected diagnosis of Wilms' tumor. The nurse should place a sign with which of the following warnings over the child's bed? A. Do not palpate abdomen. B. No venipuncture or blood pressure in left arm C. Contact precautions D. Collect all urine.

B. Initiate IV access. Rationale:Insertion of a large-bore IV catheter is the priority nursing action. The client is losing blood rapidly, has hypotension, and tachycardia. IV access will allow IV fluids and blood to be administered quickly if hypovolemia develops.

A nurse in a hospital is caring for a client who is at 38 weeks of gestation and has a large amount of painless, bright red vaginal bleeding. The client is placed on a fetal monitor indicating a regular fetal heart rate of 138/min and no uterine contractions. The client's vital signs are: blood pressure 98/52 mm Hg, heart rate 118/min, respiratory rate 24/min, and temperature 36.4° C (97.6° F). Which of the following is the priority nursing action? A. Insert an indwelling urinary catheter. B. Initiate IV access. C. Witness the signature for informed consent for surgery. D. Prepare the abdominal and perineal areas.

B. Location of the placenta Rationale:Painless, spontaneous vaginal bleeding might indicate that the client has placenta previa. Placenta previa is a condition in which the placenta is implanted low in the uterus, sometimes to the point of covering the cervical os. As the cervix effaces, the client begins to bleed. The ultrasound will show the location of the placenta and help to determine what sort of delivery the client requires and how emergent it is.

A nurse in a prenatal clinic is caring for a client who is at 38 weeks of gestation and reports heavy, red vaginal bleeding. The bleeding started spontaneously in the morning and is not accompanied by contractions. The client is not in distress and she states that she can "feel the baby moving." An ultrasound is scheduled stat. The nurse should explain to the client that the purpose of the ultrasound is to determine which of the following? A. Fetal lung maturity B. Location of the placenta C. Viability of the fetus D. The biparietal diameter

B. Hypertension Rationale: Maternal hypertension, either chronic or related to pregnancy, is the most common risk factor for placental abruption.

A nurse in a provider's office is caring for a client who is at 34 weeks of gestation and at risk for placental abruption. The nurse should recognize that which of the following is the most common risk factor for abruption? A. Cocaine use B. Hypertension C. Blunt force trauma D. Cigarette smoking

D. Abruptio placentae Rationale: The classic signs of abruptio placentae include vaginal bleeding, abdominal pain, uterine tenderness, and contractions.

A nurse in the antepartum unit is caring for a client who is at 36 weeks of gestation and has pregnancy-induced hypertension. Suddenly, the client reports continuous abdominal pain and vaginal bleeding. The nurse should suspect which of the following complications? A. Placenta previa B. Prolapsed cord C. Incompetent cervix D. Abruptio placentae

B. Bleeding Rationale: The nurse should initiate bleeding precautions for a child who has a low platelet count. Bleeding precautions involve specific measures to reduce the risk of bleeding, such as using soft-bristled toothbrushes, avoiding IM injections, and preventing constipation.

A nurse is admitting a child who has leukemia and a critically low platelet count. Which of the following precautions should the nurse initiate? A. Neutropenic B. Bleeding C. Contact D. Droplet

83 mL/hr

A nurse is preparing to administer 5% dextrose in 0.45% sodium chloride 1,000 mL IV to infuse over 12 hr. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) ______ mL/hr

A. A child who has nephrotic syndrome Rationale:A child who has leukemia is at risk for infection. Nephrotic syndrome is not an infectious disorder poses no risk to a child who has leukemia

A nurse is admitting a child who has leukemia. Which of the following clients should the nurse place in the same room with this child? A. A child who has nephrotic syndrome B. A child recovering from a ruptured appendix C. A child who has rheumatic fever D. A child who has cystic fibrosis

B. Place the child on droplet precautions. Rationale: Using the greatest risk framework, the nurse should first place the child on droplet precautions to prevent spread of the infection to other clients and staff.

A nurse is admitting a child who has suspected epiglottitis. Which of the following actions should the nurse take first? A. Administer 0.9% sodium chloride IV solution. B. Place the child on droplet precautions. C. Initiate IV antibiotics. D. Assist with obtaining an x-ray of the child's neck.

B. Placenta previa Rationale:Painless, bright red vaginal bleeding in the second or third trimester is a manifestation of placenta previa.

A nurse is admitting a client who is at 36 weeks gestation and has painless, bright red vaginal bleeding. The nurse should recognize this finding as an indication of which of the following conditions? A. Abruptio placentae B. Placenta previa C. Precipitous labor D. Threatened abortion

A. Administer magnesium sulfate IV. B. Provide a dark, quiet environment. E. Ensure that calcium gluconate is readily available. Rationale:Administer magnesium sulfate IV is correct. Magnesium sulfate IV is given as a tocolytic medication for preterm labor to relax smooth muscle of the uterus and as a treatment for preeclampsia. The underlying pathophysiology of preeclampsia is vasospasm. The nurse should closely monitor the client for signs of magnesium toxicity, such as loss of patellar reflexes, respiratory depression, cardiac arrhythmias, cardiac arrest, urinary retention, and serum magnesium levels higher than 8 mEq/L.Provide a dark, quiet environment is correct. A dark, quiet environment helps to decrease CNS stimulation, which minimizes the risk of seizures.Assess respiratory status every 4 hr is incorrect. The nurse should monitor the client's respiratory status closely because the client is at risk for respiratory depression. During an infusion of magnesium sulfate, the nurse should monitor the respiratory rate every 5 min and every 15 min during maintenance infusion. Depending on the client's response to the medication, the provider will prescribe for the vital signs to be monitored every 30 to 60 min thereafter.Evaluate neurologic status every 8 hr is incorrect. The nurse should evaluate the client's level of consciousness every hour.Ensure that calcium gluconate is readily available is correct. Calcium gluconate is the antidote for magnesium sulfate and should be readily available when administering magnesium sulfate. The nurse should be prepared to administer the medication in response to manifestations of magnesium toxicity, such as depressed respirations, oliguria, sudden drop in BP, loss of deep-tendon reflexes, and fetal distress.

A nurse is admitting a client who is at 37 weeks of gestation and has severe gestational hypertension. Which of the following actions should the nurse expect to implement? (Select all that apply.) A. Administer magnesium sulfate IV. B. Provide a dark, quiet environment. C. Assess respiratory status every 4 hr. D. Evaluate neurologic status every 8 hr. E. Ensure that calcium gluconate is readily available.

B. Keep thermometer in the toddler's room. Rationale: The nurse should keep and use dedicated equipment, such as blood pressure monitor, stethoscope, and thermometer in the client's room to prevent the spread of infection from client to client.

A nurse is admitting a toddler who has respiratory syncytial virus (RSV). Which of the following actions should the nurse take? A. Initiate airborne precautions. B. Keep thermometer in the toddler's room. C. Allow the toddler to play in the common room. D. Place the toddler in a room that has negative air pressure.

B. Obtain a detailed history. Rationale: The nurse should obtain a detailed history in order to assess for other indicators of abuse.

A nurse is assessing a child and notes several bruises. Which of the following actions should the nurse take? A. Report the suspected abuse to the authorities. B. Obtain a detailed history. C. Ask a psychiatrist to talk with the parents. D. Separate the child from the parents.

C. Elevated blood pressure Rationale: Hypertension is one of the cardinal symptoms of preeclampsia, along with excessive weight gain, edema, and albumin in the urine.

A nurse is assessing a client who is pregnant for preeclampsia. Which of the following findings should indicate to the nurse that the client requires further evaluation for this disorder? A. Increased urine output B. Vaginal discharge C. Elevated blood pressure D. Joint pain

C. Urinary output 40 mL in 2 hr Rationale: Urinary output is critical for the excretion of magnesium from the body. The nurse should report an hourly output below 30 mL/hr to the provider immediately and discontinue the medication.

A nurse is assessing a client who is receiving magnesium sulfate to treat pre-eclampsia. Which of the following findings should the nurse report to the provider? A. Respirations 16/min B. Headache for 30 min C. Urinary output 40 mL in 2 hr D. Fetal heart rate 158/min

C. Ask the parents what caused the bruises. Rationale: The nurse should gather additional data. Inconsistencies between the history and the injury are the most important criterion on which to base the decision to report suspected abuse.

A nurse is bathing a toddler and notices that she has several bruises. Which of the following actions should the nurse take first? A. Ask the toddler what caused the bruises. B. Notify the provider. C. Ask the parents what caused the bruises. D. Notify social services

D. Allow the infant to stand in the crib. Rationale:Allowing the child to participate in normal developmental activities promotes growth and development. The infant can be held and allowed to walk in a cast or orthotic device

A nurse is caring for a 10-month-old infant who is in a cast for developmental dysplasia of the hip (DDH). Which of the following strategies should the nurse implement to promote the infant's growth and development? A. Tie colorful latex balloons to the side of the crib. B. Provide a small electronic toy. C. Change the infant's diaper as soon as soiling occurs. D. Allow the infant to stand in the crib

B. Notify the provider of the situation. Rationale: The nurse should consult with the provider before proceeding. Although the parent must give consent for a minor, the nurse should obtain the minor's assent when the minor is able to give it.

A nurse is caring for a 17-year-old client who is experiencing a relapse of leukemia and is refusing treatment. The client's mother insists that the client receive treatment. Which of the following actions should the nurse take? A. Initiate the IV per the parent's request. B. Notify the provider of the situation. C. Administer a sedative to calm the client. D. Offer the client an antiemetic.

5.3 mL

A nurse is preparing to administer acetaminophen 10 mg/kg/dose to a child who weighs 28 lb. The amount available is acetaminophen 120 mg/5 mL. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) ______ mL

A. Offer the child a choice of taking the medication with juice or water. Rationale: While taking the medicine is not a choice, the child can decide what kind of fluid to take with the medication. This gives the preschool-aged child a sense of control over a stressful situation and increases the child's ability to cope.

A nurse is caring for a 4-year-old child who is resistant to taking medication. Which of the following strategies should the nurse use to elicit the child's cooperation? A. Offer the child a choice of taking the medication with juice or water. B. Tell the child it is candy. C. Hide the medication in a large dish of ice cream. D. Tell the child he will have to have a shot instead.

A. Sweat chloride test Rationale: Clients who have cystic fibrosis have an increase of sodium and chloride in both saliva and sweat. Therefore, a sweat chloride test can definitively confirm a diagnosis of cystic fibrosis.

A nurse is caring for a child who has a suspected diagnosis of cystic fibrosis. Which of the following diagnostic tests will confirm the diagnosis? A. Sweat chloride test B. A sputum culture C. A stool fat content analysis D. Pulmonary function tests

D. "It is not your fault that this happened." Rationale: The nurse should reinforce to the child that the abuse is not his fault.

A nurse is caring for a child who has been physically abused by a family member. Which of the following statements should the nurse to say to the child? A. "I promise I won't tell anyone about this." B. "Let's discuss what happened with your family." C. "Your family is bad for doing this to you." D. "It is not your fault that this happened."

260 mL

A nurse is caring for a child who is on a clear liquid diet. At lunch, the child consumed ½ cup of juice, 3 oz gelatin, 1 oz of an ice pop, and 20 mL ginger ale. How many mL should the nurse record as the child's fluid intake? ______ mL

24 mL/hr

A nurse is caring for a client is who has a deep vein thrombosis and is prescribed heparin by continuous IV infusion at 1,200 units/hr. Available is heparin 25,000 units in 500 mL D5W. The nurse should set the IV pump to deliver how many mL/hr? (Round the answer to the nearest tenth/whole number. Use a leading zero if it applies. Do not use a trailing zero.) ______ mL/hr

A. Discontinue the medication infusion. Rationale: Magnesium toxicity is manifested by bradypnea (respiratory rate less than 12/min) and absent deep tendon reflexes. The magnesium sulfate infusion should be discontinued and calcium gluconate administered via IV.

A nurse is caring for a client who has preeclampsia and is being treated with magnesium sulfate IV. The client's respiratory rate is 10/min and deep-tendon reflexes are absent. Which of the following actions should the nurse take? A. Discontinue the medication infusion. B. Prepare for an emergency cesarean birth. C. Assess maternal blood glucose. D. Place the client in Trendelenburg position.

B. Respiratory rate of 16/min Rationale: The client's respiratory rate should be at least 12/min to maintain adequate respiratory function. Magnesium toxicity causes bradypnea. Based on this finding, the nurse may continue the infusion.

A nurse is caring for a client who has severe preeclampsia and is receiving magnesium sulfate IV at 2 g/hr. Which of the following findings indicates that it is safe for the nurse to continue the infusion? A. Diminished deep-tendon reflexes B. Respiratory rate of 16/min C. Urine output of 50 mL in 4hr D. Heart rate of 56/min

A. Painless red vaginal bleeding Rationale:Placenta previa is a condition of pregnancy when the placenta implants in the lower part of the uterus, partly or completely obstructing the cervical os (outlet to the vagina). Bright red, painless vaginal bleeding occurs in the second and third trimester.

A nurse is caring for a client who is at 36 weeks of gestation and who has a suspected placenta previa. Which of the following findings support this diagnosis? A. Painless red vaginal bleeding B. Increasing abdominal pain with a nonrelaxed uterus C. Abdominal pain with scant red vaginal bleeding D. Intermittent abdominal pain following passage of bloody mucus

C. "This could result in profound bleeding." Rationale:"Pelvic rest" is essential for clients who have placenta previa because any disruption of placental blood vessels in the lower uterine segment could cause premature separation of the placenta and life-threatening hemorrhage. This means no vaginal examinations, no douching, and no vaginal intercourse.

A nurse is caring for a client who is at 37 weeks of gestation and has placenta previa. The client asks the nurse why the provider does not do an internal examination. Which of the following explanations of the primary reason should the nurse provide? A. "There is an increased risk of introducing infection." B. "This could initiate preterm labor." C. "This could result in profound bleeding." D. "There is an increased risk of rupture of the membranes."

D. Preparation for cesarean birth Rationale:A cesarean birth is indicated for all clients who have a confirmed placenta previa.

A nurse is caring for a client who is in labor at 40 weeks of gestation and reports that she has saturated two perineal pads in the past 30 min. The nurse caring for her suspects placenta previa. Which of the following is an appropriate nursing action? A. Examination to determine cervical status B. A magnesium sulfate infusion C. Initiation of pushing D. Preparation for cesarean birth

D. Monitor oxygen saturation. Rationale: The nurse should monitor the child's oxygen saturation levels to check for indications of respiratory distress or a decline child's condition

A nurse is caring for a pre-school age child who has epiglottitis with a barking cough. Which of the following actions should the nurse take? A. Initiate airborne precautions. B. Obtain a throat culture. C. Use a tongue depressor to observe the epiglottis. D. Monitor oxygen saturation.

5.6 mL

A nurse is preparing to administer amoxicillin 30 mg/kg/day divided equally every 12 hr to a toddler who weighs 33 lb. Available is amoxicillin 200 mg/5 mL suspension. How many mL should the nurse administer? (Round the answer to the nearest tenth. Use a leading zero if it applies. Do not use a trailing zero.) ______ mL

75 gtt/min

A nurse is preparing to administer cefazolin IVPB over 20 min. Available is cefazolin 1 g in 100 mL of dextrose 5% in water (D5W). The drop factor of the manual IV tubing is 15gtt/mL. The nurse should set the IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) ______ gtt/min

B. Daytime symptoms occur more than twice a week. D. Minor limitations occur with normal activity. E. Peak expiratory flow (PEF) is greater than or equal to 80% of the predicted value. Rationale:Symptoms are continual throughout the day is incorrect. Continual asthma symptoms throughout the day are seen with severe persistent asthma.Daytime symptoms occur more than twice per week is correct. A child who has mild persistent asthma will typically have daytime symptoms more than twice per week, but not daily.Nighttime symptoms occur approximately twice per month is incorrect. Nighttime symptoms occurring approximately twice per month is typical of intermittent asthma.Minor limitations occur with normal activity is correct. A child who has mild persistent asthma will have some minor limitations with normal daily activities.Peak expiratory flow (PEF) is greater than or equal to 80% of the predicted value is correct. A child who has mild persistent asthma will have a PEF greater than or equal to 80% of the predicted value.

A nurse is caring for a school-age child who has mild persistent asthma. Which of the following is an expected finding? (Select all that apply.) A. Symptoms are continuous throughout the day. B. Daytime symptoms occur more than twice a week. C. Nighttime symptoms occur approximately twice a month. D. Minor limitations occur with normal activity. E. Peak expiratory flow (PEF) is greater than or equal to 80% of the predicted value.

C. Decreased stridor Rationale:Laryngotracheobronchitis, or croup, is a condition caused by an infection of the upper airway (larynx, trachea, and bronchus) and is characterized by a barking cough. Edema and obstruction in the upper airways cause the characteristic cough and stridor (noisy breathing). The direct purpose of a cool mist tent is to humidify the inspired air, which decreases respiratory effort

A nurse is caring for a toddler who has acute laryngotracheobronchitis and has been placed in a cool mist tent. Which of the following findings indicates that the treatment has been effective? A. Barking cough B. Improved hydration C. Decreased stridor D. Decreased temperature

B. Instruct the parent to avoid pressing on the abdominal area. Rationale: The priority action is to instruct the parent to avoid pressing on the child's abdomen. These symptoms are associated with Wilms' tumor, and trauma to the mass should be avoided to prevent movement of cancer cells into other sites.

A nurse is caring for a toddler whose parent states while bathing the child she noticed a mass in his abdominal area and that his urine is a pink color. Which of the following actions is the nurse's priority? A. Schedule the child for an abdominal ultrasound. B. Instruct the parent to avoid pressing on the abdominal area. C. Determine if the child is having pain. D. Obtain a urine specimen for a urinalysis.

D. Deep tendon reflexes of +1 Rationale: Deep tendon reflexes of +1 are decreased. In a client who has preeclampsia, the nurse should expect to find an increased, rather than a decreased, deep tendon reflex.

A nurse is caring for an adolescent client who is gravida 1 and para 0. The client was admitted to the hospital at 38 weeks of gestation with a diagnosis of preeclampsia. Which of the following findings should the nurse identify as inconsistent with preeclampsia? A. 1+ pitting sacral edema B. 3+ protein in the urine C. Blood pressure 148/98 mm Hg D. Deep tendon reflexes of +1

B. Patent ductus arteriosus Rationale: With patent ductus arteriosus, the area between the pulmonary artery and aorta remains open, allowing the blood to flow through the patent ductus arteriosus and back to the pulmonary artery and lungs

A nurse is caring for an infant who has a congenital heart defect. Which of the following defects is associated with increased pulmonary blood flow? A. Coarctation of the aorta B. Patent ductus arteriosus C. Tetralogy of Fallot D. Tricuspid atresia

D. Report of headache Rationale: Manifestations of severe preeclampsia include severe (usually frontal) headache, blurred vision, photophobia, scotomas, right upper quadrant pain, irritability, presence of clonus and brisk deep tendon reflexes, nausea, vomiting, hypertension, oliguria, and proteinuria.

A nurse is completing the admission assessment of a client who is at 38 weeks of gestation and has severe preeclampsia. Which of the following is an expected finding? A. Tachycardia B. Absence of clonus C. Polyuria D. Report of headache

C. Administer albuterol prior to CPT. Rationale: Albuterol is a bronchodilator that relaxes and dilates the airway to promote air exchange. The nurse should administer the medication prior to implementing CPT to improve airway clearance. Albuterol facilitates the removal of the secretions as the chest wall is being percussed.

A nurse is planning care for a child who has cystic fibrosis and a prescription to receive chest physiotherapy (CPT). Which of the following actions should the nurse plan to take? A. Percuss each lung segment for 15 min. B. Perform CPT immediately after the child eats. C. Administer albuterol prior to CPT. D. Perform vibration during the client's inspirations.

B. Place the child in an upright position. Rationale:Placing the child in an upright position will assist in maintaining a patent airway.

A nurse is planning care for a child who has suspected epiglottitis. Which of the following actions should the nurse take? A. Obtain a throat culture. B. Place the child in an upright position. C. Transport the child to radiology for a throat x-ray. D. Visualize the epiglottis with a tongue depressor.

B. Offer option to view products of conception. Rationale:Providing support for pregnancy loss includes offering the client and her partner the options of viewing the products of conception and making arrangements for handling of the fetal remains. The client should be instructed on possible grief responses, how to manage these, and provided a referral to a support group.

A nurse is planning care for a client who is at 10 weeks of gestation and reports abdominal pain and moderate vaginal bleeding. The tentative diagnosis is inevitable abortion. Which of the following nursing interventions should be included in the plan of care? A. Administer oxygen via nasal cannula. B. Offer option to view products of conception. C. Instruct the client to increase potassium-rich foods in the diet. D. Maintain the client on bed rest

B. Body image changes Rationale:Body image changes are the most common behaviors observed in adolescents who have scoliosis and require surgery.

A nurse is planning care for an adolescent who has scoliosis and requires surgical intervention. Which of the following behaviors by the adolescent should the nurse anticipate because it is most common reaction? A. Identity crisis B. Body image changes C. Feelings of displacement D. Loss of privacy

100 gtt/min

A nurse is preparing to administer dextrose 5% in 0.45% sodium chloride 1L to infuse at 100 mL/hr. The nurse is using microtubing. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round to the nearest whole number.) ______ gtt/min

90 /min

A nurse is preparing to administer digoxin to a 6-month-old infant. Prior to administering the dose, the nurse measures the apical heart rate. The nurse should withhold the dose if the infant's apical heart rate is less than what rate? ______ /min

A. The reason why the child is taking the medication B. Written information about the medication D. The adverse effects of the medication Rationale: The reason why the child is taking the medication is correct. The nurse should include the reason why the child is taking the medication in the discharge instructions.Written information about the medication is correct. The nurse should include written information about the medication in the discharge instructions.Stopping the medication when the child feels better is incorrect. The child should finish taking the medication.The adverse effects of the medication is correct. The nurse should include the adverse effects of the medication in the discharge instructions.Using a kitchen spoon to administer the medication is incorrect. A kitchen spoon should not be used to administer the medication.

A nurse is preparing to discharge a child who has a new prescription for an oral antibiotic. Which of following information should the nurse include in the discharge instructions? (Select all that apply.) A. The reason why the child is taking the medication B. Written information about the medication C. Stopping the medication when the child feels better D. The adverse effects of the medication E. Using a kitchen spoon to administer the medication

A. Trendelenburg Rationale:Infants who have cystic fibrosis are placed in various positions to allow gravity to facilitate the removal of tenacious secretions. The nurse should identify the Trendelenburg position (head lower than body) as being contraindicated for the infant because infants do not have autonomic regulation of blood flow to the head. This position is also contraindicated for children who have head injuries.

A nurse is presenting an in-service about the use of postural drainage for infants who have cystic fibrosis. Which of the following positions should the nurse identify as being contraindicated for the infant? A. Trendelenburg B. Sitting on a nurse's lap leaning forward C. Supine D. Sitting on a nurse's lap leaning backward

B. Give the child acetaminophen for discomfort. Rationale: The child might have minor discomfort at the puncture site. The parent should offer either acetaminophen or ibuprofen due the risk of Reye syndrome associated with taking aspirin.

A nurse is providing discharge instructions to the parent of a 10-year-old child following a cardiac catheterization. Which of the following instructions should the nurse include? A. Keep the child home for 1 week. B. Give the child acetaminophen for discomfort. C. Offer the child clear liquids for the first 24 hr. D. Assist the child to take a tub bath for the first 3 days.

A. "We will give our child pancreatic enzymes with snacks and meals."

A nurse is providing discharge teaching about nutrition to the parents of a child who has cystic fibrosis (CF). Which of the following responses by the parents indicates an understanding of the teaching? A. "We will give our child pancreatic enzymes with snacks and meals." B. "We will restrict the amount of salt in our child's food." C. "I will limit my child's fluid intake." D. "I will prepare low-fat meals with limited protein for my child."

D. 1800 Rationale: The IV will infuse at 125 mL/hr. The next bag of IV solution will need to be administered at 1800.

A nurse is reviewing a client's prescription for 1,000 mL of 5% dextrose in water IV to infuse over 8 hr. At 1400, the nurse observes that there is 500 mL of solution remaining in the client's current IV bag. At what time should the nurse administer the next bag of IV solution? A. 1500 B. 1600 C. 1700 D. 1800

A. "I will give my son the enzymes between meals." Rationale: The parent should give the child pancreatic enzymes with every meal and snack.

A nurse is teaching the mother of a 5-year-old child who has cystic fibrosis about pancreatic enzymes. The nurse should understand that further teaching is necessary when the mother states which of the following? A. "I will give my son the enzymes between meals." B. "The enzymes probably won't cause many adverse effects." C. "The enzymes help him digest fat." D. "I will put the enzyme crystals in his applesauce."

C. "My child will take the enzymes to help digest the fat in foods." Rationale:Pancreatic enzymes help the body to digest fat in foods.

A nurse is teaching the mother of a child who has cystic fibrosis and has a prescription for pancreatic enzymes three times per day. Which of the following statements indicates that the mother understands the teaching? A. "My child will take the enzymes to improve her metabolism." B. "My child will take the enzymes following meals." C. "My child will take the enzymes to help digest the fat in foods." D. "My child will take the enzymes 2 hours before meals."

C. Hyporeflexia Rationale: The nurse should expect a child who has a brain tumor to exhibit hyporeflexia and hyperreflexia.

A nurse on an oncology unit is assessing a child who has a brain tumor. Which of the following findings should the nurse expect? A. Negative Babinski reflex B. Increased appetite C. Hyporeflexia D. Tachycardia

A. "As a nurse, I am required by law to report suspected child abuse." Rationale:A nurse is required by law to report suspected child abuse. Therefore, this is a truthful, non-accusatory response.

A nurse reports an incident of suspected child abuse. One of the parents of the child becomes upset and demands to know the reason for the nurse's action. Which of the following responses by the nurse is appropriate? A. "As a nurse, I am required by law to report suspected child abuse." B. "I am unable to discuss this, but I can contact my supervisor to speak with you." C. "The provider will be coming to explain the situation." D. "I reported the incident to my supervisor who decided to contact the authorities."

D. Initiate the use of a PCA pump for pain control. Rationale: The nurse should initiate the use of a PCA pump for an adolescent who is postoperative following scoliosis repair. The PCA pump allows the client to control the delivery of pain medications.

A nursing is planning care for an adolescent who is postoperative following scoliosis repair with Harrington rod instrumentation. Which of the following interventions should the nurse include in the plan of care? A. Keep the head of the bed at a 30° angle. B. Reposition the client by log rolling every 4 hr. C. Place the client in protective isolation. D. Initiate the use of a PCA pump for pain control.

B. Report the findings to a supervisor. Rationale: The greatest risk to this client is further injury from continued abuse; therefore, the first action the nurse should take is to report the findings to a supervisor. Nurses are required to report suspected cases of child and older adult abuse.

A public health nurse is assessing an older adult client who lives with a family member. The nurse identifies several bruises in various stages of healing. The client and family member explain that the bruises are a result of clumsiness. However, based on the distribution of the bruises, the nurse suspects abuse. Which of the following actions should the nurse take first? A. Document the bruises in the client's chart. B. Report the findings to a supervisor. C. Provide the client with a crisis hotline number. D. Discuss respite care with the client's family.