Pediatric Study Set 2020

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

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

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

Amount and consistency of stools. Recording the amount and consistency of the child's stools will help determine the effectiveness of pancrelipase, which is taken to decrease the bulk of feces. Blood glucose levels, bun and creatinine tests do not indicate the therapeutic effects of pancrelipase. Chloride sweat test do not indicate the therapeutic effects of pancrelipase however the results of these tests can be used to determine a dx of cystic fibrosis.

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

Apples. Apples are low sodium and supply the child with energy needed for recovery. Pretzels, canned corn, & peanut butter are high in sodium.

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

Apply pressure to the lacrimal punctual for 1 minute following administration Nurse should apply pressure to prevent the medication from entering the nasopharynx. The child should extend his head while administering med. Nurse should wipe the excess medication from the inner canthus outward.

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

At this age, your child likely believes his thoughts can cause another person's death. At this age the preschooler believes that their thoughts can cause another persons death and they can feel guilty or responsible for the death. Curiosity of what happens to the body after death usually occurs in school-age children, Understanding that death is irreversible doesn't occur until the child is approximately 9 to 10 years old.

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

I will make sure that electrical devices in the house are grounded. This response indicates an understanding of the nurse's instructions. Due to the combustible nature of oxygen, all pieces of electrical equipment in the home should be grounded to decrease the risk of a fire caused by an electrical spark. The length of the tubing should be sufficient to allow the child to move easily within the home environment. Oxygen tubing length can be up to 98 feet (30 m). Oxygen equipment and oxygen delivery should be checked at least once each day. Oxygen tanks should be stored vertically, not horizontally.

A nurse is caring for a child who has a head injury following a motor vehicle crash. Which of the following should the nurse recognize as an early manifestation of increased intracranial pressure?

Increased irritability Nurse should recognize that increased irritability, fatigue, vomiting, and headache are early signs of increased intracranial pressure. Fixed and dilated pupils, decorticate posturing, and Cheyne-Stokes respirations are a LATE sign of increased intracranial pressure

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

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

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

Keep your child away from crowded areas. The nurse should instruct the guardian to keep the child away from crowds and visitors who have an illness to decrease the risk for infection. The child should not receive the varicella immunization b/c it's a live virus and can cause an infection for a child who has neutropenia. Avoid taking rectal temperature to decrease risk of mucosal damage and infection. Limit child's intake of fresh fruit and vegetables due to risk of introducing micro-organisms.

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

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

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

Let's discuss the possible need for a transfusion with your parents The nurse should offer to involve the child's parents to understand the family's beliefs about blood transfusions. Avoid asking a "why" question because it can appear judgmental or accusatory.

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

Levalbuterol. This is a short-acting beta 2 agonist. FLuticasone (corticosteroid) and Montelukast (leukotriene modifier) are administered for long term management of asthma.

A nurse is caring for a school age girl who is being treated for frequent, severe urinary tract infections (UTIs). The nurse should recognize that which of the following statements by the parent indicates a possible cause of the UTIs?

My daughter has a BM every 4 to 5 days. Nurse should recognize that this frequency indicated the child is constipated. Large stool masses might prevent complete emptying of the bladder and lead to urinary stasis and infection. Child should wear cotton underwear to help prevent UTIs b/c nylon underwear is more likely to trap bacteria in genital area. Frequent emptying of the bladder prevents urinary stasis and infection.

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

Place the infant in semi-fowlers position for 1 hr after the feeding. The nurse should elevate the HOB by 30º to 45º for 30 min to 1 hour after feeding. The nurse should not flush the tube prior to the feeding. Additionally, when flushing the tube for medication administration, the nurse should use sterile water, rather than normal saline. The feeing solution should be administered at room temperature to decrease gastrointestinal discomfort. Auscultating over the infant's epigastric are does not ensure proper tube placement.

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

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

A nurse is assisting with the care of a school-age child who has congestive heart failure and is receiving digoxin. Which of the following manifestations should the nurse report to the provider?

Potassium 3 mEq/L Nurse should report a potassium of 3 to provider b/c a decreased potassium level can place the child at risk for digoxin toxicity Decreased edema is an expected finding associated with digoxin treatment

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

Spends a lot of time by herself. Spending time alone is expected of a 7 yr old female child. When they do spend Tims with others, they prefer to socialize with children of the same sex and age. A decline in self-esteem occurs around 11 to 14 yrs of age. Selectively choosing a best friend occurs in children who are 10 to 12 years old. Showing a competitive nature with others is seen in ages 8 to 9.

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

Stands on on foot for several seconds. This is an expected behavior. Walking backward with heel to toe is an expected behavior for a 5 yr old child. Using scissors to cut out shapes is expected for a 4 yr. old. Printing letters with a pencil is expected for a 5 yr. old.

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

Trim the child's fingernails short Nurse should instruct the guardian to trim the child's fingernails short to reduce the collection of eggs under their nails and prevent reinfection. The child should wear a one-piece sleeping outfit to minimize scratching of the perianal area. Take showers instead of baths because baths can increase the incidence of reinfection. Treatment with anti parasitic medication should be repeated in 2 weeks to prevent reinfection.

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

Urticaria/Hives Manifestations of an allergic reaction include urticaria, itching, flushing of the skin, and possible anaphylaxis.

A nurse is reinforcing teaching with the guardian of an infant who has Down syndrome. Which of the following instructions should the nurse include to decrease the child's risk of an upper respiratory infection?

Use a cool mist vaporizer in the infant's room. Cool mist vaporizer should be used to help thin respiratory secretions and decrease the infant's risk for an upper respiratory infection. Increasing fluids not limiting them will also thin respiratory secretions and decrease risk for upper respiratory infection. Rinsing the mouth with water AFTER feeding will clear the mouth of residual food and reduce risk of upper respiratory infection. The infant is at increased risk of excessive drying and chapping of the lips so applying lip balm to the infant should be encouraged especially if the infant is going to spend time outside.

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

Use facial expressions when speaking. Use facial expressions when speaking to assist in conveying the message being spoken. Avoid exaggerating the pronunciation of words because this decreases comprehension. Use hand gestures to promote understanding. Stand close to the child and face them directly as at a 45º angle to facilitate communication.

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

Vomiting. Nurse should identify that vomiting, especially unrelated to feedings, is a manifestation of digoxin toxicity and should be reported to the provider. Irritability, diaphoresis, and tachycardia are not manifestations of digoxin toxicity.

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

We will purchase a toy storage box with a lightweight lid. The parents should avoid toy boxes with heavy, hinged lids. Toddlers may suffocate or have the lid close on their head or neck, causing injury. Nurse should instruct the parents to keep toddler out of direct sun exposure between 10000 and 1400 when the sun's rays are strongest. Nurse should instruct parents to keep toddler in a crib until they have reached a height of 89cm (35in). Avoid providing snacks such as peanuts or other hard foods that can increase risk for aspiration.

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

Weight loss of 10% Nurse should expect an infant who has severe dehydration to experience weight loss of up to 10%. An infant who has severe dehydration should have mottled or cyanotic appearance, a capillary refill greater than 4 seconds, and sunken anterior fontanel.

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

You will need to have TWO negative pregnancy tests prior to starting this medication. Isotretinoin is teratogenic. Pregnancy must be ruled out prior to administration and before each refill. Pt should use 2 effective forms of contraception while on this med. Isotretinoin is administered PO. Pt. will need regular monitoring of liver function and glycemic control while on med. Avoid Vitamin A supplements b/c of increased risk for adverse effects and medication toxicity.

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

690 1oz = 30ml 4x30=120 6x30=180 6x30=180 7x30=210 =690mL

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

A child who has a fever and nuchal rigidity. A pt who has a fever and nuchal rigidity is unstable. The finding indicates bacterial meningitis, which requires urgent data collection and intervention to reduce complications for the child and prevent further spread of the infection. A pt who has a new dx of DM and an HbA1c level of 7.5% is stable. A pt who has experienced a seizure 1 hr ago and is resting is stable.

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

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

A nurse is collecting data from a 23 month old infant during a well child visit. Which of the following findings should the nurse report to the provider?

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

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

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

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

Birth weight doubled. Nurse should identify this finding as a deviation from expected growth and development. The infant's birth weight should triple by 12 months of age, therefore the nurse should report this finding to the provider. The 12 month old should be able to attempt to build a 2 block tower and fail. A vocabulary of 3 to 5 words are expected of a 12 month old. A Babinski reflex disappears approximately at age of 12 months.

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

Chronic cough. The nurse should identify that a chronic cough is an expected finding in a child who has GERD. Decreased bowel sounds are an expected finding in a child who has appendicitis. Constipation and Abdominal distention are expected findings in Hirschsprung's disease.

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

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

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

Dry cough Dry cough is an early manifestation of pertussis. Abdominal pain is a manifestation of scarlet fever. Muscle stiffness is a manifestation of poliomyelitis. Swollen eyelids are a manifestation of bacterial conjunctivitis.

A nurse is caring for a child who has a fractured tibia and is in Buck's traction. Which of the following actions should the nurse take?

Ensure the weights are hanging freely. Nurse should ensure that the weights are hanging freely for a child who is in Buck's traction. Nurse should keep the child in the center of the bed in supine position. Nurse should use palm of hands when touching a damp, plaster cast, but this is not necessary when handling a boot in Buck's traction. Buck's traction is skin traction and there are no pin sites to check.

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

Eye patch Treatment of strabismus includes covering the strong eye to strengthen the muscles in the weak eye. Biconcve lenses are not used to treat strabismus, they are used to correct myopia. Laser surgery is not indicated for strabismus. Strabismus surgery is performed to improve visual stimulation to the weak eye. Dry eyes are not a manifestation of strabismus so artificial tears are not prescribed.

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

Green, tarry stools. Green, tarry stools are an expected outcome of ferrous sulfate therapy. Therefore, this is an indication of adherence to the prescribed medication regimen. Weight gain and tolerating milk does not indicate compliance with ferrous sulfate therapy. Occasional vomiting and nausea are adverse effects of ferrous sulfate.

A nurse is caring for an adolescent client who is experiencing sickle cell crisis. Which of the following laboratory values should the nurse report to the provider?

Hgb 6 g/dL The expected reference range for an adolescent's Hgb level is 10 to 15.5 g/dL. Therefore, this level should be reported to the provider.

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

Hives Hives are an early manifestation of an anaphylactic reaction. Wheezing, angioedema, and hypotension are later manifestations of an anaphylactic reaction.

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

Hopping on one foot This is an expected finding. Skipping on alternate feet, jumping rope and roller skating are expected of a 5 yr old.

A nurse is monitoring a child who is receiving a transfusion of packed RBCs. Which of the following responses by the child is an indication of a transfusion reaction?

I am cold. Can I have an extra blanket? The nurse should identify that being cold and having chills is an indication of a transfusion reaction. A runny nose, being hungry, being sleepy are not indications of a transfusion reaction.

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

I will have my child sleep in knee, wrist, and hand splints. The nurse should reinforce with the guardian that splinting the child's joints at night will decrease pain and enhance joint function. Nurse should reinforce with guardian that the child should avoid taking naps during the day b/c this can increase joint stiffness and interfere with nighttime sleeping. Nurse should reinforce that a topical hydrocortisone is not effective in treatment if JIA. Corticosteroids are administered orally, into joints, intravenously, or intraocular for the child who has JIA.

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

Promote oxygen utilization The priority action the nurse should take when using the airway, breathing, circulation (ABC) approach to client care is promoting oxygen utilization to prevent further sickling of the red blood cells and proof adequate oxygenation of the tissue. Administration of antibiotic should be given to that any existing infection, fluid intake should be encouraged to prevent dehydration and clumping of the red blood cells, and a warm compress to the joints can be applied to reduce pain and inflammation but these are not the priority.

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

Put your child's finger under warm, running water prior to collecting blood. The nurse should instruct the parent that placing the child's finger under warm, running water increases the blood flow to the finger, which will make it easier to obtain the sample. The nurse should instruct the parent to press lightly against the child's finger with the platform of the lancet to avoid a deep puncture. The blood sample should be obtained from the side of the child's finger pad, b/s this location has more blood vessels and fewer nerve endings. Avoid steadying the finger against hard surface while puncturing the skin to avoid a deep puncture.

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

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

A nurse is collecting data from an adolescent who has manifestations of physical abuse. Which of the following actions should the nurse take?

Report the suspected abuse to the authorities. Nurses are mandatory reporters of child abuse. It is the nurse's responsibility to report any type of abuse to the appropriate agencies. This action will assist with ensuring a safe environment for the adolescent. Nurse should question the adolescent and parent about the suspected abuse separately. Use open-ended questioning to obtain the necessary subjective findings. Family psychotherapy should only take place if the perpetrator has attended individual psychotherapy and all parties agree to group therapy.

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

Sodium 150 mEq/L Hypernatremia is an adverse effect of prednisone. This level is above expected reference range for a school aged child and should be reported to provider.

A nurse is collecting data from an infant who is receiving IV therapy for fluid replacement. Which of the following findings indicates the infant's status is improving?

Sodium level of 145 mEq/L This is within the expected reference range and an indication that the infant's status is improving.