NR 328 Exam #2 Practice Questions
A nurse is assessing a child who has chronic renal failure. Which of the following findings should the nurse expect? a. Flushed face b. Hyperactivity c. Weight gain d. Delayed growth
Answer: D
A nurse is assessing an infant who has hypertrophic pyloric stenosis. Which of the following manifestations should the nurse expect? SATA a. Projectile vomiting b. Dry mucous membranes c. Currant jelly stools d. Sausage-shaped abdominal mass e. Constant hunger
Answers: A, B, E *A child with intussusception has currant jelly stools and a telescoping intestine
Identify the subacute phase and manifestations of Kawasaki disease
Subacute phase: resolution of the fever and gradual subsiding of other manifestations Irritability Peeling skin around the nails, on the palms and soles
Identify the acute phase and manifestations of Kawasaki disease
Acute phase: onset of high fever that is unresponsive to antipyretics, with development of other manifestations. Fever greater than 38.9 degrees C lasting 5 days to 2 weeks; irritability; red eyes without drainage; bright red, chapped lips; strawberry tongue with white coating or red bumps on the posterior aspect; red oral mucous membranes; swelling of hands and feet with red palms and soles; non-blistering rash; bilateral joint pain; enlarged lymph nodes
A nurse is caring for a child who is suspected to have Enterobius vermicularis. Which of the following actions should the nurse take? a. Perform a tape test b. Collect stool specimen for culture c. Test the stool for occult blood d. Initiate IV fluids
Answer: A
A nurse is caring for a client who has a major burn and is experiencing severe pain. Which of the following actions should the nurse implement to manage this client's pain? a. Administer morphine sulfate IV via continuous infusion b. Administer meperidine IM as needed c. Administer acetaminophen PO every 4 hr d. Administer hydrocodone PO every 6 hr
Answer: A
A nurse is caring for a preschooler who has nephrotic syndrome. Which of the following findings should the nurse report to the provider? a. Blood protein 5.0 g/dL b. Hgb 14.5 g/dL c. Hct 40% d. Platelet 200,000 mm3
Answer: A
When caring for a child with acute renal failure, which nursing measure requires immediate attention? A. Serum potassium concentrations in excess of 7 mEq/L B. Sodium level of 135 C. Transfusion for hemoglobin of 8 D. Mannitol and furosemide for a urine output of 2 ml/kg/hr
Answer: A
Which heart defect and hemodynamic change pairing is correct? A. Aortic stenosis and obstruction to blood flow out of the heart B. Ventricular septal defect and decreased pulmonary blood flow C. Tricuspid atresia and increased pulmonary blood flow D. Atrioventricular canal and mixed blood flow, in which saturated and desaturated blood mix within the heart or great arteries
Answer: A
You are working with a family with a child who has a congenital heart defect. Future surgery is planned, and you are teaching the parent how to reduce cardiac demands. The parent needs more teaching when she says which of the following? A. "I will wake my child for feeding every 2 hours so he can get enough calories to gain weight." B. "When I give the digoxin, I will listen to the pulse for 1 full minute." C. "I should protect my child from people who have respiratory infections." D. "I will count the number of wet diapers to be sure my child is not getting too much or too little fluid."
Answer: A
What clinical manifestation should the nurse expect to find during the assessment of an infant with coarctation of the aorta? a. Cooler lower extremities b. Low pressure in the arms c. Bounding femoral pulses d. Weak pulses in the arms
Answer: A Rationale: An infant with coarctation of the aorta, an obstructive defect of the heart, has cooler lower extremities due to localized narrowing near the insertion of the ductus arteriosus. This leads to decreased pressure in the lower extremities and weak or absent femoral pulses. The narrowing also causes increased pressure in the head and upper extremities and bounding pulses in the arms.
What does the nurse recognize as an early clinical sign of compensated shock in a child? a. Apprehension b. Hypotension c. Sleepiness d. Confusion
Answer: A Rationale: Apprehension is a clinical manifestation of compensated shock in children. Confusion is a sign of decompensated shock in children. Sleepiness is not an indication of shock. Hypotension is a sign of irreversible shock in children.
Nurse is providing anticipatory guidance about child development to parents of a preschooler. Which of the following? a. Participates in imaginary play b. Controls impulsive feelings c. Builds a collection of cards d. Expresses need for privacy
Answer: A Rationale: By 5 years of age, a preschooler should participate in imaginary and creative play, play cooperatively with peers, and speak in complete sentences. The other responses are appropriate for older children.
What is an appropriate breakfast for the hospitalized child who has celiac disease? a. Eggs, turkey bacon, fruit b. Cheerios, low-fat milk, fruit c. Pancakes, eggs, turkey bacon d. Eggs, turkey bacon, toast, low-sugar orange juice
Answer: A Rationale: Children with celiac disease cannot eat foods that contain gluten. The best option, therefore, is eggs, turkey bacon, and fruit. Toast contains gluten (unless the bread is gluten-free), as do Cheerios and pancakes. Gluten is in wheat, barley or rye. Rice is OK.
After the acute stage and during the healing process, what is the primary complication from burn injury? a. Infection b. Shock c. Renal shutdown d. Asphyxia
Answer: A Rationale: During the healing phase, local infection or sepsis is the primary complication. Respiratory problems, primarily airway compromise, and shock are the primary complications during the acute stage of burn injury. Renal shutdown is not a complication of the burn injury but may be a result of the profound shock.
What is the required number of milliliters of fluid needed per day for a 14 kg child? a. 1200 b. 1100 c. 1300 d. 1400
Answer: A Rationale: For the first 10 kg of body weight, a child requires 100 mL/kg. For each additional kilogram of body weight, an extra 50 mL is needed. 10 kg ´ 100 mL/kg/day = 1000 mL 4 kg ´ 50 mL/kg/day = 200 mL 1000 mL + 200 mL = 1200 ml/day 800 to 1000 mL is too little; 1400 mL is too much.
An infant had a gastrostomy tube placed for feedings after a Nissen fundoplication and bolus feedings are initiated. Between feedings while the tube is clamped, the infant becomes irritable, and there is evidence of cramping. What action should the nurse implement? a. Vent the gastrostomy tube. b. Withhold the next feeding. c. Burp the infant. d. Notify the health care provider.
Answer: A Rationale: If bolus feedings are initiated through a gastrostomy after a Nissen fundoplication, the tube may need to remain vented for several days or longer to avoid gastric distention from swallowed air. Edema surrounding the surgical site and a tight gastric wrap may prohibit the infant from expelling air through the esophagus, so burping does not relieve the distention. Some infants benefit from clamping of the tube for increasingly longer intervals until they are able to tolerate continuous clamping between feedings. During this time, if the infant displays increasing irritability and evidence of cramping, some relief may be provided by venting the tube. The next feeding should not be withheld, and calling the health care provider is not necessary.
What intervention is contraindicated in a suspected case of appendicitis? a. Enemas b. Palpating the abdomen c. Administration of antibiotics d. Administration of antipyretics for fever
Answer: A Rationale: In any instance in which severe abdominal pain is observed and appendicitis is suspected, the nurse must be aware of the danger of administering laxatives or enemas. Such measures stimulate bowel motility and increase the risk of perforation. The abdomen is palpated after other assessments are made. Antibiotics should be administered, and antipyretics are not contraindicated.
A child with pyloric stenosis is having excessive vomiting. The nurse should assess for what potential complication? a. Metabolic alkalosis b. Metabolic acidosis c. Hyperchloremia d. Hyperkalemia
Answer: A Rationale: Infants with excessive vomiting are prone to metabolic alkalosis from the loss of hydrogen ions. Potassium and chloride ions are lost with vomiting. Metabolic alkalosis, not acidosis, is likely.
An infant is born with a gastroschisis. Care preoperatively should include which priority intervention? a. Covering the defect with a sterile bowel bag b. Monitoring serum laboratory electrolytes c. Sterile water feedings d. Prone position
Answer: A Rationale: Initial management of a gastroschisis involves covering the exposed bowel with a transparent plastic bowel bag or loose, moist dressings. The infant cannot be placed prone, and feedings will be withheld until surgery is performed. Electrolyte laboratory values will be monitored but not before covering the defect with a sterile bowel bag.
The nurse should instruct parents to administer a daily proton pump inhibitor to their child with gastroesophageal reflux at which time? a. 30 minutes before breakfast b. Midmorning c. Bedtime d. With a meal
Answer: A Rationale: Proton pump inhibitors are most effective when administered 30 minutes before breakfast so that the peak plasma concentrations occur with mealtime. If they are given twice a day, the second best time for administration is 30 minutes before the evening meal.
How should the nurse position the pinna to visualize the eardrum of a 4-year-old child? a. Pull pinna up and back. b. Pull pinna downward. c. Pull pinna upward. d. Pull pinna down and back.
Answer: A Rationale: Pull the pinna up and back to visualize the eardrum in a child older than 3 years. Pulling the pinna upward and pulling the pinna downward are not appropriate positioning techniques for visualizing the eardrum. Pull the pinna down and back when visualizing the eardrum in an infant.
What finding is the most reliable guide to the adequacy of fluid replacement for a small child with burns? a. Urinary output of 1 to 2 mL/kg of body weight/hr b. Increased seepage from burn wound c. Falling hematocrit d. Absence of thirst
Answer: A Rationale: Replacement fluid therapy is delivered to provide a urinary output of 30 mL/hr in older children or 1 to 2 mL/kg of body weight/hr for children weighing less than 30 kg (66 pounds). Thirst is the result of a complex set of interactions and is not a reliable indicator of hydration. Thirst occurs late in dehydration. A falling hematocrit would be indicative of hemodilution. This may reflect fluid shifts and may not accurately represent fluid replacement therapy. Increased seepage from a burn wound would be indicative of increased output, not adequate hydration.
When caring for a child with probable appendicitis, the nurse should be alert to recognize which sign or symptom as a manifestation of perforation? a. Sudden relief from pain b. Anorexia c. Bradycardia d. Decreased abdominal distention
Answer: A Rationale: Signs of peritonitis, in addition to fever, include sudden relief from pain after perforation. Anorexia is already a clinical manifestation of appendicitis. Tachycardia, not bradycardia, is a manifestation of peritonitis. Abdominal distention usually increases in addition to an increase in pain (usually diffuse and accompanied by rigid guarding of the abdomen).
A 6-year-old child with Nephrotic Syndrome is being transferred out of the intensive care unit. Which child, in light of this diagnosis, is the most appropriate roommate for this child? a. 5-year-old child with a fractured femur b. 6-year-old child with pneumonia c. 4-year-old child with gastroenteritis d. 7-year-old child who has undergone surgery for a ruptured appendix
Answer: A Rationale: The 5-year-old orthopedic patient is the best choice of roommate. This child does not have an illness of viral or bacterial origin. A child with pneumonia or gastroenteritis has an illness of viral or bacterial origin and should not be placed in the same room as a child with Nephrotic Syndrome. A child who has had surgery for a ruptured appendix may have an illness of viral or bacterial origin and should not be placed in the same room as a child with Nephrotic Syndrome.
A 3-day-old infant presents with abdominal distention, is vomiting, and has not passed any meconium stools. What disease should the nurse suspect? a. Hirschsprung disease b. Intussusception c. Celiac disease d. Pyloric stenosis
Answer: A Rationale: The clinical manifestations of Hirschsprung disease in a 3-day-old infant include abdominal distention, vomiting, and failure to pass meconium stools. Pyloric stenosis would present with vomiting but not distention or failure to pass meconium stools. Intussusception presents with abdominal cramping and celiac disease presents with malabsorption.
What is the most immediate threat to life in children with thermal injuries? a. Shock b. Anemia c. Local infection d. Systemic sepsis
Answer: A Rationale: The immediate threat to life in children with thermal injuries is airway compromise and profound shock. Anemia is not of immediate concern. During the healing phase, local infection or sepsis is the primary complication.
What factor predisposes an infant to fluid imbalances? a. Immature kidney functioning b. Decreased surface area c. Lower metabolic rate d. Decreased daily exchange of extracellular fluid
Answer: A Rationale: The infant's kidneys are functionally immature at birth and are inefficient in excreting waste products of metabolism. Infants have a relatively high body surface area (BSA) compared with adults. This allows a higher loss of fluid to the environment. A higher metabolic rate is present as a result of the higher BSA in relation to active metabolic tissue. The higher metabolic rate increases heat production, which results in greater insensible water loss. Infants have a greater exchange of extracellular fluid, leaving them with a reduced fluid reserve in conditions of dehydration.
A nurse is preparing to administer digoxin to a 2-year-old child. What is the most appropriate action when the nurse is administering digoxin? a. Checking the apical heart rate and holding the medication if the pulse is below 70 beats/min b. Giving an extra dose if one is missed c. Mixing the dose with juice to disguise the taste d. Checking the apical heart rate and holding the medication if the pulse is below 90 to 110 beats/min
Answer: A Rationale: The most appropriate nursing action when digoxin is being administered is checking the apical heart rate and holding the medication if the pulse is below 70 beats/min. Never give an extra dose if one is missed, and never mix digoxin with foods or other fluids. Holding the drug if the apical pulse is below 90 to 110 beats/min is appropriate for an infant, not a 2-year-old child.
After reviewing the laboratory reports of a patient with acute glomerulonephritis, the nurse ensures that the patient is on a low-potassium diet. What is the reason for this intervention? a. The patient has oliguria. b. The patient has proteinuria. c. The patient has hypertension. d. The patient has chronic inflammation.
Answer: A Rationale: The patient with acute glomerulonephritis with oliguria will be at risk for hyperkalemia, an increase in serum potassium level. Therefore, the nurse ensures that the patient has low-potassium diet. The patient with acute glomerulonephritis may have proteinuria, but will be on a protein-restricted diet instead of a low-potassium diet. The patient with hypertension will be prescribed a sodium-restricted diet, because sodium increases blood pressure. The patient with chronic inflammation may be on a low-sugar and a fat-free diet.
What is the best method of assessing dehydration in a toddler? a. Accurate measurements of fluid intake and output b. Assessing the fontanels c. Weighing the child daily at different times d. Checking the intravenous infusion site for signs of infiltration
Answer: A Rationale: The priority nursing intervention for assessing dehydration in a child is recording of accurate measurements of fluid intake and output, including oral and parenteral intake and losses from urine, stools, vomiting, fistulas, nasogastric suction, sweat, and wound drainage. Assessing fontanels for bulging is an indicator of dehydration in infants, not toddlers. Weighing the child at the same time each day is more helpful than weighing the child at varying times. Monitoring the intravenous infusion site does not provide the nurse with assessment data that will reveal dehydration.
The parents of a newborn with an umbilical hernia ask about treatment options. The nurse's response should be based on which knowledge? a. The defect usually resolves spontaneously by 3 to 5 years of age. b. Surgery is recommended as soon as possible. c. Aggressive treatment is necessary to reduce its high mortality. d. Taping the abdomen to flatten the protrusion is sometimes helpful.
Answer: A Rationale: The umbilical hernia usually resolves by ages 3 to 5 years of age without intervention. Umbilical hernias rarely become problematic. Incarceration, where the hernia is constricted and cannot be reduced manually, is rare. Umbilical hernias are not associated with a high mortality rate. Taping the abdomen flat does not help heal the hernia; it can cause skin irritation.
An infant is brought to the emergency department with the following clinical manifestations: poor skin turgor, weight loss, lethargy, tachycardia, and tachypnea. This is suggestive of which situation? a. Water depletion b. Water excess c. Potassium excess d. Sodium depletion
Answer: A Rationale: These clinical manifestations indicate water depletion or dehydration. Edema and weight gain occur with water excess or over-hydration. Sodium or potassium excess would not cause these symptoms.
The nurse is assisting a child with celiac disease to select foods from a menu. What foods should the nurse suggest? a. Corn on the cob with butter b. Hamburger on a bun c. Spaghetti with meat sauce d. Peanut butter and crackers
Answer: A Rationale: Treatment of celiac disease consists primarily of dietary management. Although a gluten-free diet is prescribed, it is difficult to remove every source of this protein. Some patients are able to tolerate restricted amounts of gluten. Because gluten occurs mainly in the grains of wheat and rye but also in smaller quantities in barley and oats, these foods are eliminated. Corn, rice, and millet are substitute grain foods. Corn on the cob with butter would be gluten free.
A child is admitted with acute glomerulonephritis. What should the nurse expect the urinalysis during this acute phase to show? a. Hematuria and proteinuria b. Bacteriuria and hematuria c. Bacteriuria and increased specific gravity d. Proteinuria and decreased specific gravity
Answer: A Rationale: Urinalysis during the acute phase characteristically shows hematuria, proteinuria, and increased specific gravity. Proteinuria generally parallels the hematuria but is not usually the massive proteinuria seen in nephrotic syndrome. Gross discoloration of urine reflects its red blood cell and hemoglobin content. Microscopic examination of the sediment shows many red blood cells, leukocytes, epithelial cells, and granular and red blood cell casts. Bacteria are not seen, and urine culture results are negative.
The parent of a child hospitalized with acute glomerulonephritis (AGN) asks the nurse why blood pressure readings are being taken so often. What is the most appropriate response by the nurse, drawing on knowledge of AGN? a. Acute hypertension must be anticipated and identified. b. Hypotension leading to sudden shock can develop at any time. c. Blood pressure fluctuations are a common side effect of antibiotic therapy. d. Blood pressure fluctuations are a sign that the condition has become chronic.
Answer: A Rationale: Vital signs, in particular the blood pressure, provide information about the severity of acute glomerular nephritis (AGN) and early signs of complications. Acute hypertension is anticipated and requires frequent monitoring for early intervention. Blood pressure does not commonly fluctuate with antibiotic therapy. Blood pressure fluctuations are not indicative of chronic disease. Most children with AGN fully recover. Hypertension, not hypotension, is more likely with AGN.
A school-age child with acute diarrhea and mild dehydration is being given oral rehydration solution (ORS). The child's mother calls the clinic nurse because the child is also occasionally vomiting. What should the nurse recommend? a. Continuing to give ORS frequently in small amounts. b. Alternating ORS and carbonated drinks. c. Bringing the child to the hospital for intravenous fluids. d. Institute NPO status for the child for 8 hrs & resume ORS if no vomiting.
Answer: A Rationale: Vomiting is not a contraindication to the use of oral rehydration solution (ORS) unless it is severe. The mother should continue to give the ORS in small amounts and at frequent intervals. For a school-age child with mild dehydration, rehydration can be safely done at home with the use of oral solutions. Carbonated drinks should not be used; they may have a high carbohydrate content and contain caffeine, which is a diuretic and could exacerbate fluid loss and dehydration. Nothing-by-mouth (NPO) status is not indicated. Administration of small, frequent amounts of ORS is recommended.
What explains physiologically the edema formation that occurs with burns? a. Increased capillary permeability b. Decreased capillary permeability c. Vasoconstriction d. Diminished hydrostatic pressure within capillaries
Answer: A Rationale: With a major burn, capillary permeability increases, allowing plasma proteins, fluids, and electrolytes to be lost into the interstitial space, causing edema. Maximum edema in a small wound occurs about 8 to 12 hr after injury. In larger injuries, the maximum edema may not occur until 18 to 24 hr later. Vasodilation occurs, causing an increase in hydrostatic pressure.
What are some clinical manifestations of gastroesophageal reflux in infants? Select all that apply. a. Spitting up b. Failure to thrive c. Chronic cough d. Excessive crying and arching of the back
Answer: A, B, D Rationale: Clinical manifestations of gastroesophageal reflux in infants include spitting up, excessive crying and arching of the back, and failure to thrive. Heartburn and chronic cough are symptoms of gastroesophageal reflux in children, not infants.
A 5-month-old infant is seen in the well-child clinic for a complaint of vomiting and failure to grow. His birth weight was 7 lb, and he now weighs 8 lb, 10 oz. The infant's mother reports that he is taking 4 to 7 oz of formula every 4 to 5 hours, but he "spits up a lot after eating and then is hungry again." The child is noted to be alert but appears malnourished. The mother reports that his stools are brown in color, and he has 1 to 2 bowel movements every day. Based on these findings, the nurse anticipates the infant has: A. Meckel diverticulum B. Hypertrophic pyloric stenosis C. Intussusception D. Hirschprung disease
Answer: B
A burn injury involving the epidermis and varying degrees of the dermal layer that is painful, moist, red, and blistered describes which of the following? A. Superficial or first-degree burn B. Partial-thickness or second-degree burn C. Full-thickness or third-degree burn D. Fourth-degree burn
Answer: B
A nurse is caring for a 2-year-old child who has a heart defect and is scheduled for cardiac catheterization. Which of the following actions should the nurse take? a. Place on NPO status for 12 hr prior to the procedure b. Check for iodine or shellfish allergies prior to the procedure c. Elevate the affected extremity following the procedure d. Limit fluid intake following the procedure.
Answer: B
A nurse is caring for a child who has enuresis. Which of the following is a complication of enuresis? a. UTI b. Emotional problems c. Urosepsis d. Progressive kidney disease
Answer: B
A nurse is caring for a child who has watery diarrhea for the past 3 days. Which of the following is an action for the nurse to take? a. Offer chicken broth b. Initiate oral rehydration therapy c. Start hypertonic IV solution d. Keep NPO until the diarrhea subsides
Answer: B
A nurse is caring for a client who has a superficial partial-thickness burn. Which of the following actions should the nurse take? a. Administer IV infusion of 0.9% sodium chloride b. Apply cool, wet compress to the affected area c. Clean the affected area using a soft-bristle brush d. Administer morphine sulfate
Answer: B
A nurse is caring for a school-age child who has acute glomerulonephritis. Which of the following findings should the nurse report to the provider? a. BUN 8 mg/dL b. Blood creatinine 1.3 mg/dL c. Blood pressure 100/74 mmHg d. Urine output 550 mL in 24 hr
Answer: B
The greatest threat to life as a result of dehydration in children is: A. Oliguria B. Shock C. Arrhythmia D. Hypotension
Answer: B
The nurse caring for a 4-month-old infant with biliary atresia and significant urticaria can anticipate administering: A. Diphenhydramine B. Ursodiol (ursodeoxycholic acid) C. Loratidine D. Zantac
Answer: B
What is the 24-hour fluid requirement for a child weighing 32 kg? A. 1920 ml/day B. 1740 ml/day C. 1840 ml/day D. 1620 ml/day
Answer: B
A nurse is caring for an infant who has hydrocele. Which of the following actions should the nurse take? a. Prepare the child for surgery b. Explain to the parents that the issue with self-resolve c. Retract the foreskin and cleanse several times daily d. Refer the family for genetic counseling
Answer: B Hydrocele is fluid in the scrotum and resolves spontaneously in the majority of cases
What is an important part of establishing therapeutic communication with adolescents? a. Explaining procedures using short sentences and simple words b. Building a foundation for a trusting relationship c. Communicating through transition objects d. Using nonverbal techniques
Answer: B Rationale: Building a foundation for a trusting relationship is an important part of establishing therapeutic communications with adolescents. Many adolescents have a difficult time understanding nonverbal cues; therefore this is not an important part of therapeutic communication with adolescents. Communicating through transition objects, such as dolls or toys, and using short sentences with simple words are both helpful strategies for use with younger children.
What care must the nurse take when obtaining abdominal measurements for a child with Hirschsprung disease? a. Obtain abdominal circumference just above the umbilicus. b. Mark the point of measurement on the abdomen with a pen. c. Obtain and document the measurement once a day. d. Remove the tape after each measurement is recorded.
Answer: B Rationale: Distention of the abdomen is a serious sign in the child with Hirschsprung disease. The nurse must obtain the abdominal circumference with a paper tape measure. The abdomen must be marked with a pen at the point of measurement to maintain reliability of later measurements. Abdominal circumference is usually taken at the level of the umbilicus or the widest part of the abdomen. This measurement must be obtained with the vital sign measurements and is recorded in a serial order so that any change is evident. When frequent measurements are needed, the tape is left in place beneath the child to reduce the stress each time it is removed. Remember to teach the parents of the child that has surgery with a colostomy that the colostomy is usually reversible.
The nurse should explain to the parents that their child is receiving furosemide for severe congestive heart failure because of which effect? a. An ACE inhibitor b. A diuretic c. A form of digitalis d. A β-blocker
Answer: B Rationale: Furosemide is a diuretic used to eliminate excess water and salt to prevent the accumulation of fluid associated with congestive heart failure. Furosemide is not a β-blocker. Furosemide is not a form of digitalis. Furosemide is not an angiotensin-converting enzyme (ACE) inhibitor.
The nurse is providing discharge teaching to the parent of an infant who has a prescription for digoxin. Which of the following instructions should the nurse include? a. "If your baby vomits, you should repeat the dose immediately'" b. "Give the correct dose of medication at the same time everyday." c. "Do not offer your baby fluids after giving the medication." d. "Digoxin will increase your baby's heart rate."
Answer: B Rationale: Give digoxin at regular intervals, usually every 12 hours, such as at 8 AM and 8 PM. • Administer the drug carefully by slowly directing it to the side and back of the mouth. • Do not mix the drug with foods or other fluids because refusal to consume these would result in inaccurate intake of the drug. • If the child has teeth, give water after administering the drug; whenever possible, brush the teeth to prevent tooth decay from the sweetened liquid. • If a dose is missed, do not give an extra dose or increase the dose. Stay on the same medication schedule. • If the child vomits, do not give a second dose. • If more than two consecutive doses have been missed, notify the physician or other designated practitioner. • Frequent vomiting, poor feeding, or slow heart rate can be signs of digoxin toxicity; if they occur, contact the physician. • If the child becomes ill, notify the physician or other designated practitioner immediately. • Keep digoxin in a safe place, preferably in a locked cabinet. • In case of accidental overdose of digoxin, call the nearest poison control center immediately.
After cardiac catheterization of a child, which assessment finding is a cause of concern to the nurse? a. The pulse distal to the catheterization site is weak. b. The affected extremity feels cool when touched. c. The child is in bed with the affected extremity straight. d. The child has resumed oral intake with clear liquids.
Answer: B Rationale: If the affected extremity feels cool when touched, arterial obstruction may be present. The health care provider must be notified immediately. A weak pulse distal to the site for the first few hours after catheterization is not a cause for concern. However, the pulse should gradually increase in strength. The child's usual diet can be resumed as soon as tolerated, beginning with sips of clear liquids and advancing as the condition allows. The child must take in enough fluids to ensure adequate hydration. Blood loss, nothing by mouth (NPO) status, and diuretic actions of dyes used during the procedure increase the risk for hypovolemia and dehydration. The child must be kept in bed, with the affected extremity maintained straight for several hours, to promote healing of the cannulated vessel.
Nephrotic syndrome is a clinical state that includes hypoalbuminemia, hyperlipidemia, and what? a. Creatine and edema b. Proteinuria and edema c. Uric acid and edema d. Blood urea nitrogen and proteinuria
Answer: B Rationale: Nephrotic syndrome is a clinical state that includes massive proteinuria, hypoalbuminemia, hyperlipidemia, and edema.
Baby sustained minor oral burns from drinking hot milk that had been warmed in a microwave for 3 mins. Teaching needs? a. Warm the milk in the microwave only for 1 minute. b. Never use a microwave for warming milk. c. Provide only chilled milk to the baby to avoid oral burns. d. Warm the milk in the microwave for 30 seconds only.
Answer: B Rationale: Parents should be advised that they should never thaw or rewarm expressed milk in a microwave because it can cause uneven warming of milk and result in oral burns. They should be advised to thaw the frozen milk by either placing it in lukewarm water.
The nurse is providing care for a school-age child after appendectomy. The child is worried that abdominal pain again will result in another operation. What action does the nurse take? a. Explains that if there is pain only medicines will be given b. Explains that the problem is fixed and will not return c. Explains that there is no need to worry about anything d. Explains that an operation is not as painful as the child thinks
Answer: B Rationale: Telling the child that the problem is fixed and will not return alleviates the child's fears. Explaining that the child will be given medicines for the pain makes the child anticipate pain and increases anxiety. Telling the child that there is no need to worry may not be convincing, because the child understands simple and clear messages. Telling the child that an operation is not painful is not appropriate, because the child may find the concept of surgery traumatic.
A nurse is assessing a 3 year-old-child at a routine wellness checkup. Which finding would the nurse expect at this age? a. Skips and hops on one foot b. Stands on one foot for a few seconds c. Has a vocabulary of 1,500 words d. Walks backwards heel to toe
Answer: B Rationale: The nurse should expect a 3 year-old-child to be able to stand on one foot for a few seconds, ascend stairs on alternate feet, and jump off of the bottom step.The other responses are appropriate for 4 & 5 year olds.
A nurse is caring for a child who has Hirschsprung's disease. Which of the following actions should the nurse take? a. Encourage a high-fiber, low protein, low-calorie diet b. Prepare the family for surgery c. Place an NG tube for decompression d. Initiate bed rest
Answer: B - a client with Hirschsprung's requires surgery to remove the affected segment of the intestine. *These patients require a low-fiber, high-calorie-high protein diet. This disease is managed nutritionally, placing an NG tube is an inappropriate action. Bed rest is initiated to prevent further bleeding in a patient with Meckel's diverticulum
A nurse is caring for an infant who has just returned from PACU following cleft lip and palate repair. Which of the following actions should the nurse take? a. Remove the packing in the mouth b. Place the infant in an upright position c. Offer a pacifier with sucrose d. Assess the mouth with a tongue blade
Answer: B - to facilitate drainage and prevent aspiration *Packing in the mouth should remain for 2-3 days. Objects in the mouth like a pacifier or tongue blade can injure the surgical site and should be avoided
Nurse is assessing an infant with severe dehydration. What assessment findings are associated? SATA a. The skin is elastic. b. There are decreased tears. c. The capillary refill is 5 seconds. d. The fontanels are sunken.
Answer: B, C, D Rationale: The infant with severe dehydration has poor peripheral circulation and delayed capillary refill due to reduced blood volume. The capillary refill is delayed to more than 4 seconds. The skin appears acrocyanotic or mottled with tenting. The child has hyperpnea, or deep and rapid respiration, as a result of poor oxygenation. Physical examination of the eyes reveals sunken eyes with absence of tears. The fontanels will be sunken.
A 10-year-old child suffered extensive second- and third-degree burns in an apartment fire. His weight is 75 lb (34 kg). Fluid replacement therapy will optimally: A. Result in an hourly urine output of 1 ml/kg B. Result in an hourly urine output of 20 ml/kg C. Result in an hourly urine output of 30 ml/kg D. Maintain a systolic blood pressure in the 95th percentile for the child's weight
Answer: C
A 16-month-old has a history of diarrhea for 3 days with poor oral intake. He received intravenous fluids, has tolerated some oral fluids in the emergency department, and is being discharged home. Instructions for diet for this child should include: A. BRAT diet (bananas, rice, applesauce, and toast) for 24 hours, then a soft diet as tolerated B. Chicken or beef broth for 24 hours, then resume a soft diet C. Offer a regular diet as child's appetite warrants D. Keep on clear liquids and toast for 24 hours
Answer: C
A 3-year-old boy is seen in the clinic at 8:30 pm with a history of vomiting for 2 days and poor oral intake; he has voided once since the previous day. Examination reveals a lethargic child sitting on the mother's lap. He has a capillary refill of 4 seconds, apical heart rate of 128, respiratory rate of 32, and poor skin turgor. Stated body weight is 25 kg. Based on this information, the nurse anticipates performing which of the following? A. Demonstrating to the mother how to give 5 to 10 ml of Pedialyte by mouth every 5 to 10 minutes B. Administering an intravenous fluid bolus of 450 ml of 5% dextrose in water over 60 minutes C. Administering an intravenous fluid bolus of 500 ml of 0.9% normal saline over 20 minutes D. Administering an intravenous fluid bolus of 1000 ml of 5% dextrose and 0.45% normal saline over 30 minutes
Answer: C
A 4-day-old infant is seen in the emergency department for a possible seizure earlier in the day. The infant was being breastfed but without much success, so an aunt gave him a bottle of water. The infant continued to cry, and the mother was too exhausted to breastfeed, so another bottle of water was given while someone went to the store to purchase infant formula. The pregnancy, delivery, and postpartum history reveal no particular problems for this term infant that might contribute to seizures. The physical examination is unremarkable, with the exception of hypertonic reflexes. The infant is awake, alert, and sucking on his fists. Diagnostic studies are obtained, including an electrocardiogram. The nurse anticipates which of the following as the possible explanation for the infant's condition? A. Serum potassium of 3.9 mEq B. Serum glucose of 69 mg C. Serum sodium of 118 mEq D. Arterial pH of 7.34
Answer: C
A formerly preterm infant who had surgery for necrotizing enterocolitis is now 6 months old and has short-bowel syndrome. He is unable to absorb most nutrients taken by mouth and is totally dependent on parenteral nutrition, which he receives via a central venous catheter. The clinic nurse following this infant is aware that this infant should be closely observed for the development of: A. Gastroesophageal reflux B. Chronic diarrhea C. Cholestasis D. Failure to thrive
Answer: C
A nurse is caring for a client who has a moderate burn. Which of the following actions should the nurse take? a. Maintain immobilization of the affected area b. Expose affected area to the air c. Initiate a high-protein, high-calorie diet d. Implement contact isolation
Answer: C
A nurse is providing teaching to the caregiver of an infant who has a prescription for digoxin. Which of the following instructions should the nurse include? a. "Do not offer your baby fluids after giving the medication" b. "Digoxin increases your baby's heart rate" c. "Give the correct dose of medication at regularly scheduled times d. "If your baby vomits a dose, you should repeat the dose to ensure that the correct amount is received"
Answer: C
The most common type of dehydration in children occurs when electrolyte and water deficits are present in approximately balanced proportions. This is called ________________ dehydration. A. Hypotonic B. Hypertonic C. Isotonic D. Hyponatremic
Answer: C
The nurse is caring for a 3 year old boy whose parents noticed that his eyes are reddened with no discharge, and his palms and soles of the feet are red, swollen and peeling. Upon examination, the nurse's assessment includes dry, cracked lips and a "strawberry tongue." the nurse most likely suspects? a. Varicella b. Rheumatic Fever c. Kawasaki Disease d. Congenital Heart Defect
Answer: C
The nurse is caring for a school-age girl who has had a cardiac catheterization. The child tells the nurse that her bandage is "too wet." The nurse finds the bandage and bed soaked with blood. What nursing action is most appropriate to institute initially? a. Apply a new bandage with more pressure. b. Notify the provider. c. Apply direct pressure above the catheterization site. d. Place the child in Trendelenburg position.
Answer: C
The physician suggests that surgery be performed for patent ductus arteriosus (PDA) to prevent which complication? a. Decreased workload on the left side of the heart b. Right-to-left shunt of blood c. Pulmonary vascular congestion d. Cyanosis
Answer: C
What nutritional component should be altered in the infant with heart failure (HF)? a. Decrease in protein b. Increase in fluids c. Increase in calories d. Decrease in fats
Answer: C
What intervention can the nurse implement to help involve a younger child in the physical examination process? a. Limit the number of people in the room. b. Perform the examination as quickly as possible. c. Allow the child to handle or hold the equipment. d. Examine painful areas last.
Answer: C Rationale: By allowing the child to handle or hold the equipment, the nurse involves the child in the physical examination process. Examining painful areas last allays fear but will not involve the child in the physical examination. Performing the examination as quickly as possible increases the speed of examination but does not necessarily help the child feel more involved in the physical examination. Limiting the number of people in the room will ensure privacy but will not encourage the child to become involved in the physical examination.
Which term describes the thickening and flattening of the tips of the fingers and toes that is thought to occur as a result of chronic tissue hypoxemia? a. Raynaud phenomenon b. Polycythemia c. Clubbing d. Hypercyanotic spells
Answer: C Rationale: Clubbing is a thickening and flattening of the tips of the fingers and toes that is thought to occur as a result of chronic tissue hypoxemia and polycythemia. Polycythemia is an increased number of red blood cells. Hypercyanotic, or "blue," spells are often seen in infants with tetralogy of Fallot; the affected infant becomes acutely cyanotic and hyperpneic. Raynaud phenomenon is an autoimmune disease.
An air pressure enema ordered to reduce an intussusception, child passes a normal brown stool. What is most appropriate? a. Decreasing the rate of intravenous fluids b. Measuring the abdominal girth c. Notifying the health care provider immediately d. Administering prescribed prophylactic antibiotics
Answer: C Rationale: Passage of a normal stool indicates that the intussusception has resolved. Notification of the health care provider is essential to determine whether a change in the treatment plan is indicated. Measurement of the abdominal girth may be indicated, but notifying the provider is the priority. The health care provider may alter the treatment plan but should be notified first. If the treatment plan is altered, antibiotics may not be needed.
The nurse is caring for a child who had an appendectomy following a ruptured appendix and peritonitis. Which intervention does the nurse perform first for the child with risk for infection? a. Maintain nasogastric (NG) tube gastric decompression. b. Monitor temperature, blood pressure, and pulse oximeter. c. Monitor wound status, integrity, and type of dressing. d. Listen for bowel sounds and bowel activity.
Answer: C Rationale: Postoperative care for a child with a ruptured appendix and peritonitis requires thorough care. The first action is to monitor the wound status, integrity, and type of dressing to detect infection and plan interventions. The nurse should then monitor vital signs such as temperature, blood pressure, and pulse oximeter to detect fever or hemodynamic instability. The child should have nothing by mouth (NPO) while receiving IV fluids to prevent dehydration. The NG tube is kept on low continuous gastric decompression until there is evidence of intestinal activity. This prevents nausea and vomiting; it also promotes drainage of gastrointestinal secretions and acid. The nurse should evaluate bowel sounds and function by listening to bowel sounds and observing for other signs of bowel activity. **Remember pre-op pain may suddenly go away (means the appendix has ruptured); also no enemas in a child with abdominal pain until appendicitis is ruled out.
Nurse is caring for a 3-yo who is the victim of a house fire. Child has burns to the face & head. What is priority? a. Nutritional b. Cardiac c. Respiratory d. Neurologic
Answer: C Rationale: The primary emphasis during the emergent phase is the treatment of burn shock and the management of pulmonary status since respiratory obstruction poses the biggest threat to the patient's life. Monitoring vital signs, output, fluid infusion, and respiratory parameters are ongoing activities in the hours immediately after injury. Following assessment of the patient's airway, the nurse can assess the patient's nutritional, cardiac, and neurologic statuses.
The nurse is teaching the parents of preschoolers about preventing urinary tract infections (UTIs). What strategies should the nurse instruct the parents to use to prevent UTIs? Select all that apply. a. "Give cranberry juice to your children on a regular basis." b. "Do not allow your children to urinate in public toilets." c. "Encourage your children to drink 6 to 8 glasses of water each day." d. "Ensure that your children evacuate their bowels regularly."
Answer: C, D Rationale: Drinking adequate amounts of water promotes flushing of the normal bladder and lowers the concentration of pathogens in the bladder. It also helps enhance the antibacterial properties of the renal medulla. Constipation can cause bladder obstruction and increase the risk of UTI. Thus, the parents must ensure that the children clear their bowels regularly. Much has been reported about the use of cranberry products for prevention of UTI. Initially it was thought to alter the urine acidity, but studies have not shown that ingestion results in a lower pH; but instead it appeared to decrease the adherence of certain bacteria to the bladder wall. Recent review of the literature showed that cranberry products did not significantly reduce the occurrence of symptomatic UTI overall or in any of the subgroups, including children. Because the benefit is small, cranberry juice cannot currently be recommended for prevention of UTIs. Other cranberry preparations need to be quantified using standardized methods to ensure the potency before being evaluated in clinical studies or recommended for use. If the child is outside the home and has a desire to void, the child should be allowed to use the public toilets, because holding urine in the bladder for a long time can increase the risk of UTI.
A 3-month-old infant has a hypercyanotic spell while the mother is holding him. What should the nurse teach the room to do first? a. Assess for neurologic defects. b. Do nothing--it will go away. c. Begin cardiopulmonary resuscitation. d. Place the child in the knee-chest position.
Answer: D
A nurse is planning care of a child who has a UTI. Which of the following interventions should the nurse include? a. Administer an antidiuretic b. Restrict fluids c. Evaluate the child's self-esteem d. Encourage frequent voiding
Answer: D
The parents of a 3-year-old child with congenital heart disease are afraid to let their child play with other children because of possible overexertion. How should the nurse reply to this concern? a. The child needs to understand that peers' activities are too strenuous. b. Constant parental supervision is needed to avoid overexertion. c. The parents should meet all the child's needs. d. The child needs opportunities to play with peers.
Answer: D
What preparation should the nurse consider when educating a school-age child and the family for heart surgery? a. Unfamiliar equipment should not be shown. b. Explain that an endotracheal tube will not be needed if the surgery goes well. c. Discussion of postoperative discomfort and interventions is not necessary before the procedure. d. Let the child hear the sounds of a cardiac monitor, including alarms.
Answer: D
What should the nurse teach the parents about caring for the infant with gastroesophageal reflux (GER)? a. Place the infant supine after feeding. b. Feed the infant just before bedtime. c. Place the infant on the side to sleep. d. Avoid vigorous play after feedings.
Answer: D Rationale: Parents should avoid vigorous play with the infant after feedings to prevent regurgitation. The head of the bed may be raised to 30 degrees after feedings to prevent discomfort and regurgitation. Parents must avoid feeding the infant just before bedtime to avoid GER. The infant must not be positioned on the side to sleep. The Task Force on Sudden Infant Death Syndrome recommends that the infant be placed in the supine position when sleeping. As the infant ages foods to avoid are: citrus, fatty foods, peppermint.
What is an early sign of heart failure? a. Inability to sweat b. Bradycardia c. Increased urine output d. Resting tachypnea
Answer: D Rationale: Tachypnea is one of the early signs of heart failure. Bradycardia is not an early symptom of heart failure. The inability to sweat is not a sign of heart failure; in fact, many affected children are diaphoretic. Urine output is usually decreased, not increased, in heart failure.
What manifestation in the infant does the nurse associate with hypertrophic pyloric stenosis? a. Abdominal pain b. Edema at the extremities c. Distended lower abdomen d. Projectile vomiting
Answer: D Rationale: The infant with hypertrophic pyloric stenosis has projectile vomiting, a sign of obstruction. Vomit may be ejected 3 to 4 feet from the infant when in a side-lying position or 1 foot or more when in a supine position. The infant does not have abdominal pain, except for discomfort due to hunger (will be ravenous after vomiting). The infant is hungry and shows signs of dehydration. There is no edema at the extremities. The infant has a distended upper abdomen as a result of gas and fluid above the level of the obstruction. Will possibly have an olive shaped abdominal mass.
4 year old is receiving vaccine. What is the best approach? a. Before giving the vaccine, give the information about the vaccine. b. Explain that the pain will be only be a minute & it will be over quickly. c. Ask the caregiver to step outside and have a nurse aide help. d. Give the child a syringe to hold, a simple explanation, reassurance.
Answer: D Rationale: The nurse should understand that the child is frightened; therefore asking the parent to step out of the room would further increase the child's anxiety. the first two options would not allow for the child to interact with the equipment, which is important as most preschoolers desire concrete vocabulary and interaction with medical equipment. allowing the child to hold and touch the equipment while offering an explanation is the best option.
What is the best method of assessing dehydration in a toddler? a. Assessing the fontanels b. Weighing the child daily at different times c. Checking the intravenous infusion site for signs of infiltration d. Accurate measurements of fluid intake and output
Answer: D Rationale: The priority nursing intervention for assessing dehydration in a child is recording of accurate measurements of fluid intake and output, including oral and parenteral intake and losses from urine, stools, vomiting, fistulas, nasogastric suction, sweat, and wound drainage. Assessing fontanels for bulging is an indicator of dehydration in infants, not toddlers. Weighing the child at the same time each day is more helpful than weighing the child at varying times. Monitoring the intravenous infusion site does not provide the nurse with assessment data that will reveal dehydration.
True or False: A daily weight is not indicated in a child with Nephrotic Syndrome.
Answer: False Rationale: A daily weight taken at the same time every day, with the child wearing the same clothing, is the most accurate way to determine fluid gains and losses.
True or False. Two children are sharing clay to make things. This is an example of parallel play.
Answer: False Rationale: An example of parallel play is when both children are engaged in similar activities in proximity to each other; however, they are each engaged in their own play, such as Brian and Kristina playing with their own toys side by side. Sharing clay is characteristic of associative play. A group of children playing a board game is characteristic of cooperative play. Playing alone on the mother's lap is an example of solitary play.
True or False. A daily weight is not indicated in a child with Nephrotic Syndrome.
Answer: False Rationale: False. A daily weight taken at the same time every day, with the child wearing the same clothing, is the most accurate way to determine fluid gains and losses.
The nurse is teaching the parents of preschoolers about preventing urinary tract infections (UTIs). What strategies should the nurse instruct the parents to use to prevent UTIs? (Select all that apply). a. "Ensure that your children evacuate their bowels regularly." b. "Encourage your children to drink 6 to 8 glasses of water each day." c. "Give cranberry juice to your children on a regular basis." d. "Put a diaper on your child overnight." e. "Do not allow your children to urinate in public toilets."
Answers: A, B
A nurse is assessing a child who has rotavirus infection. Which of the following are expected findings? SATA a. Fever b. Vomiting c. Watery stools d. Bloody stools e. Confusion
Answers: A, B, C
A nurse is assessing a child who has nephrotic syndrome. Which of the following findings should the nurse expect? SATA a. Urine dipstick +2 protein b. Edema in the ankles c. Hyperlipidemia d. Polyuria e. Anorexia
Answers: A, B, C, E
A child with periorbital edema, decreased urine output, pallor, and fatigue is admitted to the pediatric unit. The child is being examined for acute glomerulonephritis. Which of the following nursing measures should be considered? Select all that apply. A. On examination there is usually a mild to moderate elevation in blood pressure compared with normal values for age, although severe hypertension may be present. B. Urinalysis during the acute phase characteristically shows hematuria, proteinuria, and increased specific gravity. C. The primary objective is to reduce the excretion of urinary protein and maintain protein-free urine. D. Assessment of the child's appearance for signs of cerebral complications is an important nursing function because the severity of the acute phase is variable and unpredictable. E. Because these children are particularly vulnerable to upper respiratory tract infection, protect them from contact with infected roommates, family, or visitors.
Answers: A, B, D
A nurse is caring for a client who has major burns and suspected septic shock. Which of the following findings are consistent with septic shock? SATA a. Increased body temperature b. Altered sensorium c. Decreased capillary refill time d. Decreased urine output e. Increased bowel sounds
Answers: A, B, D
Because children with celiac disease must limit their intake of products containing gluten in wheat, rye, oats, and barley, they are at risk for which of the following nutritional deficiencies? Select all that apply. A. Iron deficiency anemia B. Folic acid deficiency C. Zinc deficiency D. Vitamin A, D, E, and K deficiency E. Vitamin B12 deficiency
Answers: A, B, D
What are some clinical manifestations of gastroesophageal reflux in infants? Select all that apply. a. Spitting up b. Failure to thrive c. Chronic cough d. Excessive crying and arching of the back
Answers: A, B, D Rationale: Clinical manifestations of gastroesophageal reflux in infants include spitting up, excessive crying and arching of the back, and failure to thrive. Heartburn and chronic cough are symptoms of gastroesophageal reflux in children, not infants.
A nurse is teaching a parent of an infant about GI reflux disease. Which of the following should the nurse include in the teaching? SATA a. Offer frequent feedings b. Thicken formula with rice cereal c. Use a bottle with a one-way valve d. Position baby upright after feedings e. Use a wide-based nipple for feedings
Answers: A, B, D - all will help decrease vomiting episodes *Wide-based nipple and bottle with a one-way valve is for cleft lip and palate.
A nurse is assessing an infant who has coarctation of the aorta. Which of the following findings should the nurse expect? SATA a. Weak femoral pulses b. Cool skin of the lower extremities c. Severe cyanosis d. Clubbing of the fingers e. Low blood pressure
Answers: A, B, E
A nurse is caring for a child who has Meckel's diverticulum. Which of the following manifestations should the nurse expect? SATA a. Abdominal pain b. Fever c. Mucus and blood in stools d. Vomiting e. Rapid, shallow breathing
Answers: A, C *B, D, and E are all manifestations of appendicitis
A nurse is caring for a male infant who has an epispadias. Which of the following findings should the nurse expect? SATA a. Bladder exstrophy b. Inability to retract foreskin c. Widened pubic symphysis d. Urethral opening on the dorsal side of the penis e. Pain
Answers: A, C, D
A nurse is teaching a group of caregivers about E. coli. Which of the following information should the nurse include in the teaching? SATA a. Severe abdominal cramping occurs b. Watery diarrhea is present for more than 5 days c. It can lead to hemolytic uremic syndrome d. It is a foodborne pathogen e. Antibiotics are given for treatment
Answers: A, C, D *Antibiotics can worsen an E. coli infection and are therefore not recommended
The nurse is caring for a 4-year-old girl with a history of frequent urinary tract infections. What should the nurse be aware of before obtaining a urine sample? Select all that apply. A. To obtain a clean-catch urine specimen, have the child sit on the toilet facing backward toward the tank. B. Because children who have a UTI will have painful urination, have the child drink a large amount of fluid before obtaining the sample. C. The specimen must be fresh—less than 1 hour after voiding with storage at room temperature or less than 4 hours after voiding with refrigeration. D. If a urinalysis obtained by a bag specimen is negative, a specimen still needs to be obtained by catheterization or suprapubic aspiration. E. The key to distinguishing a true UTI from asymptomatic bacteriuria is the presence of pyuria. F. Because the child is febrile, the nurse should immediately start an antimicrobial and then obtain a urine culture.
Answers: A, C, E
When giving discharge instructions to a parent post hypospadias repair, the nurse recognizes a need for more teaching when the mother says which of the following? Select all that apply. A. "I know I should never clamp off the catheter." B. "My child can take a tub bath when we arrive home because it will soothe the area." C. "An antibacterial ointment may be applied to the penis daily for infection control." D. "Fluids should be monitored and rationed to prevent fluid overload." E. "My child should avoid straddle toys, sandboxes, swimming, and rough activities until allowed by the surgeon."
Answers: A, C, E
You are working with a new graduate on the pediatric unit and your patient is returning from the cardiac catheterization laboratory. You feel the graduate understands the important nursing interventions when she says which of the following? Select all that apply. A. "Check pulses, especially below the catheterization site, for equality and symmetry." B. "Check vital signs, which may be taken as frequently as every 30 to 45 minutes, with special emphasis on the heart rate, which is counted for 1 full minute for evidence of dysrhythmias or bradycardia." C. "Special attention needs to be given to the BP, especially for hypertension, which may indicate hemorrhage or bleeding from the catheterization site." D. "Check the dressing for evidence of bleeding or hematoma formation in the femoral or antecubital area." E. "Allow the child to ambulate because this will prevent skin breakdown from lying so long in one place."
Answers: A, D
A nurse is assessing an infant who is suspected of having a coarctation of the aorta. Which of the following findings should the nurse expect? (Select all that apply). a. Cool skin of the lower extremities b. Cyanosis c. Clubbing of the fingers d. Blood pressure lower in the legs compared to the arms e. Weak pedal pulses
Answers: A, D, E
A nurse is caring for an infant who has ambiguous genitalia. Which of the following actions should the nurse take? SATA a. Prepare the child for surgery b. Test the child's infant's function c. Cover the genitals with a sterile dressing d. Refer the family for genetic counseling e. Explain the need for a chromosomal analysis
Answers: A, D, E
A nurse is caring for a child who is suspected of having rheumatic fever. Which of the following findings should the nurse expect? SATA a. Erythema marginatum (rash) b. Continuous joint pain of the digits c. Tender, subcutaneous nodules d. Decreased erythrocyte sedimentation rate e. Elevate C-reactive protein
Answers: A, E
Hepatitis A virus is transmitted by which of the following? Select all that apply. A. Breast milk from mother with HAV B. Ingestion of contaminated food C. Fecal-oral route D. Casual contact with infected person E. Blood transfusion
Answers: B, C
A nurse is teaching a parent of a child who has a UTI. Which of the following should the nurse include in the teaching? SATA a. Wear nylon underpants b. Avoid bubble baths c. Empty bladder completely with each void d. Watch for manifestations of infection e. Wipe perineal area back to front
Answers: B, C, D
Nurse is assessing an infant with severe dehydration. What assessment findings are associated? SATA a. The skin has decreased turgor. b. There are decreased tears. c. The capillary refill is 5 seconds. d. The fontanels are sunken.
Answers: B, C, D Rationale: he infant with severe dehydration has poor peripheral circulation and delayed capillary refill due to reduced blood volume. The capillary refill is delayed to more than 4 seconds. The skin appears acrocyanotic or mottled with tenting. The child has hyperpnea, or deep and rapid respiration, as a result of poor oxygenation. Physical examination of the eyes reveals sunken eyes with absence of tears. The fontanels will be sunken.
A nurse is assessing a child who has a UTI. Which of the following are manifestations of a UTI? SATA a. Night sweats b. Swelling of the face c. Pallor d. Pale-colored urine e. Fatigue
Answers: B, C, E
A nurse is assessing an infant who has heart failure. Which of the following findings should thee nurse expect? SATA a. Bradycardia b. Cool extremities c. Peripheral edema d. Increased urinary output e. Nasal flaring
Answers: B, C, E
A nurse is caring for a child who has acute post-streptococcal glomerulonephritis (APSGN). Which of the following manifestations should the nurse expect? SATA a. Pale urine b. Periorbital edema c. Ill appearance d. Decreased creatinine e. Hypertension
Answers: B, C, E
You are discharging a 5-week-old infant with a congenital heart defect who will be going home on digoxin. Which of the following answers by the father indicate the need for more teaching? Select all that apply. A. "I know I give the drug carefully by slowly directing it to the side and back of the mouth." B. "I give the medication every 12 hours, and I can place it in a bit of formula so I know the baby will take it." C. "If I miss a dose, I don't give an extra dose, but I give the next dose as ordered." D. "If the baby vomits, I should give a second dose." E. "If more than two doses have been missed, I should call the doctor."
Answers: B, D
You are working in the pediatric clinic, and a child presents with symptoms that are suspicious of the acute phase of Kawasaki disease. Which of the following symptoms are included? Select all that apply. A. Periungual desquamation (peeling that begins under the fingertips and toes) of the hands and feet is present. B. The bulbar conjunctivae of the eyes become reddened, with clearing around the iris. C. A temporary arthritis is evident, which may affect the larger weight-bearing joints. D. Inflammation of the pharynx and the oral mucosa develops, with red, cracked lips and the characteristic "strawberry tongue." E. Loud pansystolic murmur along with ECG changes are present.
Answers: B, D
A nurse is assessing an infant who has a suspected UTI. Which of the following are expected findings? SATA a. Increase in hunger b. Irritability c. Decrease in urination d. Vomiting e. Fever
Answers: B, D, E
A nurse is caring for a client who has a skin graft. Which of the following manifestations indicate infection? SATA a. Pink color to subcutaneous fat b. Unstable body temperature c. Generation of granulation tissue d. Subeschar hemorrhage e. Change in skin color around the affected area
Answers: B, D, E
A nurse is caring for an infant who has obstructive uropathy. Which of the following findings should thee nurse expect? SATA a. Decreased urine flow b. UTI c. Intrauterine polyhydramnios d. Concentrated urine e. Hydronephrosis
Answers: B, E
What nursing care guidelines should the nurse implement when communicating with children? Select all that apply. a. Be honest only when it is helpful for the child. b. Avoid extended eye contact and other threatening gestures. c. Minimize or ignore fearful reactions by children to enhance coping skills. d. Hurry through the exam to help the child cope with the experience. e. Communicate through transitional objects such as dolls and puppets.
Answers: B, E Rationale: Transitional objects such as dolls and puppets should be used to enhance communication with children. Avoid extended eye contact and other threatening gestures when communicating with children. Be honest with children at all times, not just when it is perceived to be helpful for the child. It is not helpful to hurry through the exam, which will stress the child rather than help them to cope with the experience. Never minimize or ignore fearful reactions by children; instead allow them to express their concerns and fears in a nonthreatening environment.
Identify the convalescent phase of Kawasaki disease
Convalescent phase: no manifestations seen except altered laboratory findings. Resolution in about 6 to 8 weeks from onset.
List the depth, appearance, sensation, and healing of fourth-degree burns
Deep full thickness (Fourth-degree) -Damage to all layers of the skin that extends to the muscle, tendons, and bones -Color variable, dull, and dry with charring -Possible visible ligaments, bone, or tendons -No pain is present -Heals within weeks to months -Scarring is present and grafting is required -Amputation possible
List the depth, appearance, sensation, and healing of second-degree (deep partial thickness) burns
Deep partial thickness (second-degree) -Damage to the entire epidermis and some parts of the dermis -Sweat glands and hair follicles remain intact -Mottled -Red to white in color with blisters -Blanches with pressure -Moderate edema -Painful -Sensitive to temperature changes and light touch -Healing can go beyond 21 days with scarring
List the depth, appearance, sensation, and healing of third-degree burns
Full thickness (third-degree) -Damage to the entire epidermis and dermis with possible damage to the subcutaneous tissue -Nerve endings, hair follicles, and sweat glands are destroyed -Red to tan, black, brown, or waxy in color -Dry, leathery appearance -No blanching -As burn heals, painful sensations return and severity of pain increases -Heals within weeks to months -Scarring is present -Grafting is required
Alteration in health diagnosis for enuresis
Inappropriate urination must occur at least twice a week for at least 3 months, and the child must be at least 5 years of age before there's consideration about diagnosing enuresis
List the depth, appearance, sensation, and healing of first-degree burns
Superficial (first degree) -Damage to the epidermis -Pink to red in color with no blisters -Blanches with pressure -Painful -Heals within 3-7 days with no scarring
List the depth, appearance, sensation, and healing of second-degree (superficial partial thickness) burns
Superficial partial thickness (second degree) -Damage to the entire epidermis with intact dermal elements -Moist -Red in color with blisters -Blanches with pressure -Mild to moderate edema -No eschar -Painful -Sensitive to temperature changes and light touch -Heals in less than 21 days with variable scarring