Pediatrics ATI Practice A
A nurse is teaching the parent of a preschooler about ways to prevent acute asthma attacks. Which of the following statements by the parents indicates an understanding of the teaching? A. "I will use a humidifier in my child's room at night." B. "I will give my child a cough suppressant every 6 hours if he has a cough." C. "I should avoid using a wet mop on my floors when I am cleaning." D. "I should keep my child indoors when I mow the yard."
D. "I should keep my child indoors when I mow the yard." Rationale: The nurse should instruct the parent to keep the preschooler indoors during lawn maintenance or when the pollen count is increased. Guarding against exposure to known allergens found outdoors, such as grass, tree, and weed pollen, will decrease the frequency of the preschooler's asthma attacks.
A hospice nurse is caring for a preschooler who has a terminal illness. One of the preschooler's parents tells the nurse that they cannot cope anymore and are thinking about moving out of the house. Which of the following statements should the nurse make? A. "It is important that you provide emotional support for your family at this time." B. "You have to do what you feel is best. Everything will turn out fine." C. "I know how you feel. This is an extremely stressful time for your family." D. "L
D. "Let's talk about some of the ways you have handled previous stressors in your life." Rationale: This statement offers a general lead to allow the parent to express their feelings and previous actions when faced with stressful situations. It also helps the parent to focus on ways that they can cope with the current situation.
A school nurse is preparing to administer atomoxetine 1.2 mg/kg/day PO to a school-aged child who weights 75 lbs. Available is atomoxetine 40 mg/capsule. how many capsules should the nurse administer per day?
1 capsule
A nurse in an ED is caring for an adolescent experiencing an anaphylaxis reaction. Which of the following is the priority action of the nurse? A. Elevate the head of the child's bed. B. Insert a large bore IV catheter for the child. C. Determine the allergen that caused the child's reaction. D. Administer epinephrine IM to the child.
D. Administer epinephrine IM to the child. Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority action is administering epinephrine IM to the child. During an anaphylactic reaction, histamine release causes bronchoconstriction and vasodilation. This is an emergency because ultimately this causes decreased blood return to the heart.
A nurse is creating a plan of care for a school-aged child who has heart disease and developed heart failure. Which of the following interventions should the nurse include in the plan? A. Provide small, frequent meals for the child. B. Schedule time in the play room for the child. C. Weigh the child weekly. D. Maintain the child in a supine position.
A. Provide small, frequent meals for the child. Rationale: The metabolic rate of a child who has heart failure is high because of poor cardiac function. Therefore, the nurse should provide small, frequent meals for the child because it helps to conserve energy.
A nurse is a providers office is preparing to administer vaccinations to a toddler during a well-child visit. Which of the actions should the nurse plan to take? (kid has increased RR & HR; allergy to Neomycin) A. Withhold the measles, mumps, and rubella (MMR) vaccine. B. Withhold the diphtheria, tetanus, and pertussis (DTaP) vaccine. C. Withhold the influenza vaccine. D. Withhold the tuberculin skin test (TST).
A. Withhold the measles, mumps, and rubella (MMR) vaccine. Rationale: The nurse should recognize that an allergy to neomycin with an anaphylactic reaction is a contraindication for receiving the MMR vaccine. Clients who have a severe allergy to eggs or gelatin should not receive this vaccine.
A nurse is preparing an adolescent for a lumbar puncture. Which of the following actions should the nurse take? A. Place a cardiac monitor on the adolescent prior to the procedure B. Apply topical analgesic cream to the site 1 hr prior to the procedure. C. Keep the adolescent in a semi-Fowler's position for 4 hr following the procedure. D. Restrict fluids for 2 hr following the procedure.
B. Apply topical analgesic cream to the site 1 hr prior to the procedure. Rationale: The nurse should apply a topical analgesic to the lumbar site 1 hr prior to the procedure to decrease the adolescent's pain while the lumbar needle is inserted.
A nurse is assessing a 3-year-old toddler at a well-child visit. Which of the following manifestations should the nurse report to the provider? A. Blood pressure 90/50 mm Hg B. Respiratory rate 45/min C. Weight 14.5 kg (32 lb) D. Heart rate 110/min
B. Respiratory rate 45/min Rationale: The nurse should identify that a respiratory rate of 45/min is above the expected reference range of 20 to 25/min for a 3-year-old toddler and can indicate respiratory dysfunction and acute respiratory distress. Therefore, the nurse should report this finding to the provider.
A nurse is caring for an adolescent who received a kidney transplant. Which of the following finding should the nurse identify as an indication the adolescent is rejecting the kidney? A. Negative leukocyte esterase B. Serum creatinine 3.0 mg/dL C. Negative urine protein D. Urine output 40 mL/hr
B. Serum creatinine 3.0 mg/dL Rationale: Creatinine is a byproduct of protein metabolism and is excreted from the body through the kidneys. An elevated serum creatinine level, therefore, can be an indication that the kidneys are not functioning. The nurse should identify that the adolescent's serum creatinine level is higher than the expected reference range of 0.4 to 1.0 mg/dL for an adolescent and can indicate rejection of the kidney
A nurse is assessing a toddler who has gastroenteritis and is exhibiting manifestations of dehydration. Which of the following findings is the nurse's priority? A. Skin breakdown B. Hypotension C. Hyperpyrexia D. Tachypnea
D. Tachypnea Rationale: When using the airway, breathing, and circulation approach to client care, the nurse's priority finding is the toddler's tachypnea. Tachypnea is a result of the kidneys being unable to excrete hydrogen ions and produce bicarbonate, which leads to metabolic acidosis.
A nurse is caring for a toddler who is experiencing acute diarrhea and has moderate dehydration. Which of the following nutritional items should the nurse offer the child? A. Apple juice B. Peanut butter C. Chicken broth D.Oral rehydration solution
D.Oral rehydration solution Rationale: A toddler who has acute diarrhea should consume an oral rehydration solution to replace electrolytes and water by promoting the reabsorption of water and sodium. This promotes recovery from dehydration.
A nurse is assessing a school-aged child immediately following an appendix rupture repair. Which of the following findings should the nurse expect? A. Purulent nasogastric drainage B. Absence of peristalsis C. Passage of dark red stool with mucus D. WBC count 6,000/mm3
B. Absence of peristalsis Rationale: The nurse should expect absence of peristalsis immediately following a perforated appendix repair, until the bowel resumes functioning.
A nurse is providing discharge teaching to the parent of a child who is 1 week postoperative following a cleft palate repair. For which of the following members of the interprofessional team should the nurse initiate a referral? A. Occupational therapist B. Speech therapist C. Respiratory therapist D. Physical therapist
B. Speech therapist Rationale: The nurse should initiate a referral for a speech therapist for a child who is postoperative following a cleft palate repair. A child who has a cleft palate will require speech therapy immediately following the repair to support speech development and future articulation.
0915:Guardians report that lately the child has had severe itching and is breaking out with sores on their eyebrows, wrists, and ankles. The "sores started to bleed." Guardians report no relief with application of the topical hydrocortisone cream.0930:Child is alert. Multiple small erythematous papules with some scaling noted on the child's eyebrows, forearms, and lower legs bilaterally.1015:Provider in to evaluate the child. Discharge to home after medication administration of new prescriptions
"We should apply a skin emollient immediately after bathing our child" "We should keep our child's fingernails trimmed short" "We should use a mild detergent for our laundry"
A nurse is providing teaching to the parent of a school-aged child who has a new prescription for oral nystatin for the treatment of oral candidacies. Which of the following instructions should the nurse include? A. "Shake the medication prior to administration." B. "Provide the medication through a straw." C. "Rinse the child's mouth with water immediately after giving the medication." D. "Mix the medication with applesauce if the child dislikes the taste."
A. "Shake the medication prior to administration." Rationale: The nurse should instruct the parent to shake the medication prior to administration to disperse the medication evenly within the suspension.
A nurse is assessing an infant who has a ventricular septal defect. Which of the following findings should the nurse expect? A. Loud, harsh murmur B. Dysrhythmias C. Weak femoral pulses D. High blood pressure
A. Loud, harsh murmur Rationale: The nurse should expect to hear a loud, harsh murmur with a ventricular septal defect due to the left-to-right shunting of blood, which contributes to hypertrophy of the infant's heart muscle.
A nurse is assessing a school-aged child who has peritonitis. Which of the following findings should the nurse expect? A. Hyperactive bowel sounds B. Abdominal distention C. Bradycardia D.Bloody stool
B. Abdominal distention Rationale: The nurse should identify that abdominal distention is an expected finding of peritonitis. Peritonitis is an inflammation of the lining of the abdominal wall. This inflammation in the abdomen, along with the ileus that develops, causes abdominal distention. Other manifestations include chills, irritability, and restlessness.
A nurse is caring for a preschooler who is scheduled for hydrotherapy treatment for wound debridement following a burn injury. Which of the following actions should the nurse take prior to the procedure? A. Apply topical antimicrobial ointment to the child's wound. B. Place a mesh gauze dressing over the child's wound. C. Administer an analgesic to the child. D. Initiate prophylactic antibiotic therapy for the child.
C. Administer an analgesic to the child. Rationale: Hydrotherapy for debridement of a wound is an extremely painful procedure which requires analgesia and/or sedation. When pain is controlled, it leads to reduced physiological demands on the body caused by stress and decreases the likelihood of children developing depression and post-traumatic stress disorder.
A nurse in the emergency department is caring for a toddler who has partial-thickness burns on their right arm. Which of the following actions should the nurse take? A. Insert a nasogastric tube. B. Initiate prophylactic antibiotic therapy. C. Cleanse the affected area with mild soap and water. D. Apply a topical corticosteroid to the affected area.
C. Cleanse the affected area with mild soap and water. Rationale: The nurse should wash the affected area with mild soap and water to remove any loose tissue that could cause infection.
A nurse is reviewing the lumbar puncture results of a school-aged child who has suspected bacterial meningitis. Which of the following findings should the nurse identify as an indication of bacterial meningitis? A. Decreased cerebrospinal fluid pressure B. Decreased WBC count C. Increased protein concentration D. Increased glucose level
C. Increased protein concentration Rationale: The nurse should identify that an increased protein concentration in the spinal fluid is a finding that can indicate bacterial meningitis.
A nurse is preparing to collect a sample from a toddler for a sickle-turbidity test. Which of the following actions should the nurse plan to take? A. Obtain a sputum specimen. B. Perform an Allen test. C. Perform a finger stick. D. Obtain a stool specimen.
C. Perform a finger stick. Rationale: The nurse should perform a finger stick on a toddler as a component of the sickle-turbidity test. If the test is positive, hemoglobin electrophoresis is required to distinguish between children who have the genetic trait and children who have the disease.
A nurse is caring for a school-aged child who is reviving chemotherapy and is severely immunocompromised. Which of the following actions should the nurse take? A. Use surgical asepsis when providing routine care for the child. B. Administer the measles, mumps, and rubella (MMR) vaccine to the child. C. Screen the child's visitors for indications of infection. D. Infuse packed RBCs.
C. Screen the child's visitors for indications of infection. Rationale: A child who is severely immunocompromised is unable to adequately respond to infectious organisms, resulting in the potential for overwhelming infection. Therefore, the nurse should screen the child's visitors for indications of infection.
A nurse is ascultating the lungs of an adolescent who has asthma. The nurse should identify the following sound as which of the following? A. Biot respiration B. Cheyne-Stokes respiration C. Tachypnea D. Bradypnea
C. Tachypnea Rationale: The nurse should identify the sound heard during auscultation as tachypnea, which is a rapid, regular breathing pattern. This breathing pattern often occurs with anxiety, fever, metabolic acidosis, or severe anemia.
A nurse is assessing the vital signs of a 10-year-old child following a burn injury. The nurse should identify that which of the following findings is an indication of early septic shock? A. Blood pressure 130/90 mm Hg B. Heart rate 60/min C. Temperature 39.1° C (102.4° F) D. Urinary output 100 mL/hr
C. Temperature 39.1° C (102.4° F) Rationale: The nurse should identify that a temperature of 39.1° C (102.4° F) is above the expected reference range of 37° to 37.5° C (98.6° to 99.5° F) for a 10-year-old child. The nurse should expect a child who has early septic shock to have a fever and chills.
A nurse is providing dietary-teaching to the parents of a child who has celiac disease. The nurse should recommend that the parent offer which of the following foods to the child? A. Wheat crackers B. Rye bread C. Barley soup D. White Rice
D. White Rice Rationale: The nurse should recommend that the parent offer white rice to the child because it is a gluten-free food. The nurse should instruct the parent that the child will remain on a lifelong gluten-free diet and the child should not consume oats, rye, barley, or wheat, and sometimes lactose deficiency can be secondary to this disease.
A nurse in an emergency department is caring for an adolescent who has severe abdominal pain due to appendicitis. Which of the following locations should the nurse identify as McBurneys Point?
A - The nurse should identify this area of the client's abdomen as McBurney's point. This area of the right lower quadrant located about two-thirds of the way between the umbilicus and the client's anterosuperior iliac spine is the area where a client who has appendicitis is most likely to report pain and tenderness.
A nurse is reviewing the laboratory report of a school-aged child who is experiencing fatigue. Which of the following findings should the nurse recognize as an indication of anemia? A. Hematocrit 28% B. Hemoglobin 13.5 g/dL C. WBC count 8,000/mm3 D. Platelets 250,000/mm3
A. Hematocrit 28% Rationale: The nurse should recognize that this hematocrit level is below the expected reference range of 32% to 44% for a school-age child. The child can exhibit fatigue, lightheadedness, tachycardia, dyspnea, and pallor due to the decreased oxygen-carrying capacity.
A nurse is reviewing the laboratory report of a 7-year-old child who is going through chemotherapy. which of the following lab values should the nurse report to the provider? A. Hgb 8.5 g/dL B. WBC count 9,500/mm3 C. Prealbumin 18 mg/dL D. Platelets 300,000/mm3
A. Hgb 8.5 g/dL Rationale: A child receiving chemotherapy is at risk for anemia due to the chemotherapy effects on the blood-forming cells of the bone marrow. The development of anemia is diagnosed through laboratory testing of hemoglobin and hematocrit levels. The nurse should recognize that a hemoglobin level of 8.5 g/dL is below the expected reference range of 10 to 15.5 g/dL for a 7-year-old child and should be reported to the provider.
A nurse is caring for an infant who has RSV. Which of the following actions should the nurse implement for infection control? A. Have a designated stethoscope in the infant's room. B. Place the infant in a room equipped with negative airflow. C. Administer palivizumab as prescribed for the infant. D. Remove gloves after leaving the infant's room.
A. Have a designated stethoscope in the infant's room. Rationale: The nurse should initiate droplet precautions for an infant who has RSV because the virus is spread by direct contact with respiratory secretions. Therefore, designated equipment, such as a blood pressure cuff and a stethoscope, should be placed in the infant's room.
A nurse is caring for a 15-year-old client who is married and is scheduled for a surgical procedure. The client asks, "who should sign my surgical consent?" which of the following responses' should the nurse make? A. "You can sign the consent form because you are married." B. "Your spouse should sign the consent form for you." C. "Your parent should sign the consent form for you." D. "You can appoint a legal guardian to sign the consent form."
A. "You can sign the consent form because you are married." Rationale: The nurse should inform the adolescent that marriage gives adolescents the legal right to consent to surgical procedures and sign other legal documents that they would not otherwise be able to sign due to their age.
A nurse is assessing a 4 year old child at a well-child visit. Which of the following developmental milestones should the nurse expect to witness? A. Identifies right from left hand B. Uses a utensil to spread butter C. Cuts an outlined shape using scissors D. Draws a stick figure with seven body parts
C. Cuts an outlined shape using scissors Rationale: The nurse should recognize that an expected developmental milestone of a 4-year-old child is using scissors to cut out a shape.
A nurse is caring for a school-aged child who is receiving cefazolin via intermittent IV bolus. The child suddenly develops diffuse flushing of the skin and angioedema. After discontinuing the medication infusion, which of the following medications should the nurse administer first? A. Epinephrine B. Diphenhydramine C. Albuterol D. Prednisone
A. Epinephrine Rationale: This child is most likely experiencing an anaphylactic reaction to the cefazolin. According to evidence-based practice, the nurse should first administer epinephrine to treat the anaphylaxis. Epinephrine is a beta adrenergic agonist that stimulates the heart, causes vasoconstriction of blood vessels in the skin and mucous membranes, and triggers bronchodilation in the lungs.
a nurse is caring for a school-aged child who has experienced a tonic-clonic seizure. Which of the following actions should the nurse take during the immediate postictal period? A. Place the child in a side-lying position. B. Give the child a high-carbohydrate snack C. Administer an oral sedative to the child. D.Delay documentation until the child is fully alert.
A. Place the child in a side-lying position. Rationale: The nurse should place the child in a side-lying position to prevent aspiration.
A nurse is providing teaching to the parent of an infant who has diaper dermatitis. The nurse should instruct the parent to apply which of the following to the affected area? A. Zinc oxide B. Antibiotic ointment C. Talcum powder D. Antiseptic solution
A. Zinc oxide Rationale: Diaper dermatitis is a common inflammatory skin disorder caused by contact with an irritant such as urine, feces, soap, or friction, and takes the form of scaling, blisters, or papules with erythema. Providing a protective barrier, such as zinc oxide, against the irritants allows the skin to heal.
A nurse is caring for a preschooler whose father is going home home for a few hours while another relative stays with the child. Which of the following statements should the nurse make to explain to the child when their father will return? A. "Your daddy will be back at 7 p.m." B. "Your daddy will be back after you eat." C. "Your daddy will be back in the morning." D."Your daddy will be back after he takes care of your brother."
B. "Your daddy will be back after you eat." Rationale: Preschoolers make sense of time best when they can associate it with an expected daily routine, such as meals and bedtime. Therefore, the child comprehends time best when it is explained to them in relation to an event they are familiar with, such as eating.
A nurse is preparing to administer an immunization to a 4-year-old child. Which of the following actions should the nurse plan to take? A. Request that the child's caregiver leave the room during the immunization. B. Administer the immunization using a 24-gauge needle. C. Inject the immunization slowly after aspirating for 3 seconds. D.Place the child in a prone position for the immunization.
B. Administer the immunization using a 24-gauge needle. Rationale: The nurse should administer an immunization for a 4-year-old child using a 22- to 25- gauge needle to minimize the amount of pain the child experiences.
A nurse is caring for a school-aged child who is receiving a blood transfusion. Which of the following manifestations should alert the nurse to a possible hemolytic transfusion reaction? A. Laryngeal edema B. Flank Pain C. Distended neck veins D. Muscular weakness
B. Flank Pain Rationale: The nurse should recognize that flank pain is caused by the breakdown of RBCs and is an indication of a hemolytic reaction to the blood transfusion.
A nurse in the ED is caring for a school-aged child who has appendicitis and rates their pain as 7 on a scale of 1-10. which of the following actions should the nurse take? A. Instill a 500 mL tap water enema. B. Give morphine 0.05 mg/kg IV. C. Administer polyethylene glycol 1g/kg PO D. Apply a heating pad to the child's abdomen.
B. Give morphine 0.05 mg/kg IV. Rationale: A pain level of 7 on a scale of 0 to 10 is considered severe. The nurse should administer an analgesic medication for pain relief.
A nurse is creating a plan of care for an infant who has an epidural hematoma from a head injury. Which of the following interventions should the nurse include in the plan of care? A. Position the infant side-lying with their head at a 0° to 5° angle. B. Perform a neurological assessment every 4 hr. C. Suction the infant's nares to remove secretions. D. Implement seizure precautions for the infant.
D. Implement seizure precautions for the infant. Rationale: An infant who has an epidural hematoma is at great risk for seizure activity. Therefore, the nurse should implement seizure precautions for the child.
A nurse is teaching the parents of an infant ways to prevent sudden infant death syndrome (SIDS). Which of the following instructions should the nurse include? A. "Place the infant in a prone position to sleep." B. "Allow the infant to sleep on a large pillow." C. "Use a soft mattress in the infant's crib." D. "Give the infant a pacifier at bedtime."
D. "Give the infant a pacifier at bedtime." Rationale: The nurse should inform the parent that protective factors against SIDS include breastfeeding and the use of a pacifier when the infant is sleeping.
A nurse is admitting a school-aged child who has pertussis. Which of the following actions should the nurse take? A. Place the child in a room with positive-pressure airflow. B. Place the child in a room with negative-pressure airflow. C. Initiate contact precautions for the child. D.Initiate droplet precautions for the child.
D.Initiate droplet precautions for the child. Rationale: The nurse should initiate droplet precautions for a child who has pertussis, also known as whooping cough. Pertussis is transmitted through contact with infected large-droplet nuclei that are suspended in the air when the child coughs, sneezes, or talks.
A school nurse is assessing an adolescent who has multiple burns in various stages of healing. Which of the following behaviors should the nurse identify as possible indication of physical abuse? A. Expresses a reluctance to leave home B. Provides a detailed description of how the burns occurred C. Denies discomfort during assessment of injuries D. Describes strong relationships with peers
C. Denies discomfort during assessment of injuries Rationale: The nurse should suspect child maltreatment in the form of physical abuse if the adolescent has a blunted response to painful stimuli or injury.
A nurse is an Urgent care clinic is assessing an adolescent who has an upper respiratory infection. Which of the following findings should the nurse identify as a clinical manifestation of pertussis? A. Inflamed throat with exudate B. Purulent eye drainage C. Dry, hacking cough D. Koplik spots on buccal mucosa
C. Dry, hacking cough Rationale: The nurse should identify that a dry, hacking cough is a manifestation of pertussis. This disease usually begins with indications of an upper respiratory tract infection, which includes a dry, hacking cough that is sometimes more severe at night.
A nurse is planning care for a school-aged child who is in the oliguric phase of acute kidney injury and has a sodium level of 129 mEq/L. Which of the following interventions should the nurse include in the plan? A. Administer ibuprofen to the child for a temperature greater than 38º C (100.4º F). B. Assess the child's blood pressure every 8 hr. C. Weigh the child weekly at various times of the day. D. Initiate seizure precautions for the child.
D. Initiate seizure precautions for the child. Rationale: A sodium level of 129 mEq/L indicates hyponatremia and places the child at increased risk for neurological deficits and seizure activity. The nurse should complete a neurologic assessment and implement seizure precautions to maintain the child's safety.
A nurse is providing teaching about play activities for social development to the parents of a preschooler. Which of the following play activities should the nurse recommend for the child? A. Playing pat-a-cake B. Using a push-pull toy C. Creating a scrapbook D. Playing dress-up
D. Playing dress-up Rationale: The nurse should instruct the parents that at the preschool age, play should focus on social, mental, and physical development. Therefore, playing dress-up is a recommended play activity for this child.
A nurse is assessing a school-aged child who has meningitis. Which of the following findings is the priority of the nurse to report to the provider? A. Reports a headache as 6 on a 0 to 10 pain scale B. Petechiae on the lower extremities C. Nuchal rigidity D. Positive Kernig's sign
B. Petechiae on the lower extremities Rationale: The presence of a petechial or purpuric rash on a child who is ill can indicate the presence of meningococcemia. This type of rash indicates the greatest risk of serious rapid complications from sepsis and should be reported immediately to the provider.
A nurse is reviewing the laboratory results of an infant who is receiving treatment for severe dehydration. The nurse should identify which of the following lab values indicates that the treatment is working? A. Potassium 2.9 mEq/L B. Sodium 140 mEq/L C. Urine specific gravity 1.035 D. BUN 25 mg/dL
B. Sodium 140 mEq/L Rationale: The nurse should identify that a sodium level of 140 mEq/L is within the expected reference range of 134 to 150 mEq/L and indicates the current treatment regimen the infant is receiving for dehydration is effective.
A charge nurse in an emergency department is preparing an in-service for a group of newly licensed nurses about the manifestations of child maltreatment. Which of the following manifestations should the charge nurse include as an indication of physical maltreatment? A. Recurrent urinary tract infections B. Symmetric burns of the lower extremities C. Failure to thrive D. Lack of subcutaneous fat
B. Symmetric burns of the lower extremities Rationale: The nurse should include that symmetric burns to the lower extremities can indicate physical abuse. The patterns are usually characteristic of the method or object used, such as cigar or cigarette burns, or burns in the shape of an iron.
A nurse is planning care of a toddler who has a serum lead level of 4 mcg/dL. Which of the following actions should the nurse plan to take? A. Instruct the parents to decrease the calcium in their toddler's diet. B. Prepare the toddler for chelation therapy. C. Refer the family to Child Protective Services. D. Schedule the toddler for a yearly rescreening.
D. Schedule the toddler for a yearly rescreening. Rationale: The nurse should schedule the toddler for a lead level rescreening in 1 year and educate the family on ways to prevent exposure.
A nurse in an emergency department is performing a physical assessment on a 2-week-old male newborn. Which of the following findings is the priority for the nurse to report to the provider? A.Excoriated scrotal area B. Multiple capillary hemangiomas C. Depressed posterior fontanel D. Substernal retractions
D. Substernal retractions Rationale: When using the airway, breathing, and circulation approach to client care, the nurse should determine that the priority finding to report to the provider is substernal retractions. This finding indicates the newborn is experiencing increased respiratory effort, which could quickly progress to respiratory failure.
A nurse is caring for a school-aged child who is in Buck's traction following a leg fracture 24-hours ago. Which of the following actions should the nurse take? A. Change the child's position every 2 hr. B. Clean the peripheral pin sites with chlorhexidine solution every 4 days. C. Assess peripheral pulses once every 4 hr. D. Ensure that the head of the bed is elevated to a 90° angle.
C. Assess peripheral pulses once every 4 hr. Rationale: Buck's traction is a type of skin traction that can be used to immobilize extremities prior to surgery. The nurse should provide frequent neurovascular checks at least every 4 hr after the first 24 hr of placement in Buck's traction. The nurse should monitor and report signs of neurovascular impairment in the extremities such as cyanosis, edema, pain, absent pulses, and tingling.
A nurse is caring for a 15-year-old client following a head injury. Which of the following finding should the nurse identify as an indication that the child is developing syndrome of inappropriate antidiuretic hormone secretion? A. Sodium 148 mEq/L B. Urine specific gravity 1.020 C. Mental confusion D. Weak peripheral pulses
C. Mental confusion Rationale: A child who has a head injury can develop SIADH as a result of altered pituitary function, leading to an oversecretion of antidiuretic hormone. Oversecretion of antidiuretic hormone leads to a decrease in urine output, hyponatremia, and hypoosmolality due to overhydration. As the hyponatremia becomes more severe, mental confusion and other neurologic manifestations such as seizures can occur.
A school nurse is assessing an adolescent who has scoliosis. Which of the following findings should the nurse expect? A. Increase in anterior convexity of the lumbar spine B. Increased curvature of the thoracic spine C. Lateral flexion of the neck D. A unilateral rib hump
D. A unilateral rib hump Rationale: When assessing an adolescent for scoliosis, the school nurse should expect to see a unilateral rib hump with hip flexion. This results from a lateral S- or C-shaped curvature to the thoracic spine resulting in asymmetry of the ribs, shoulders, hips, or pelvis. Scoliosis can be the result of a neuromuscular or connective tissue disorder, or it can be congenital in nature.
The nurse is interviewing the parent of an 18-month-old toddler during a well-child visit. The nurse should identify that which of the following findings indicates a need to assess the toddler for hearing loss? A. The toddler has a vocabulary of 25 words. B. The toddler developed a mild rash following a recent varicella immunization. C. The toddler's Moro reflex is absent. D. The toddler received tobramycin during a hospitalization 2 weeks ago.
D. The toddler received tobramycin during a hospitalization 2 weeks ago. Rationale: The nurse should identify tobramycin as an aminoglycoside, which is an ototoxic medication that can cause mild to moderate hearing loss, and should assess the toddler for a hearing impairment.
A nurse is caring for a child who has spastic cerebral palsy. Which of the following findings should the nurse expect? (Select all that apply) A. Negative Babinski reflex B. Ankle clonus C. Exaggerated stretch reflexes D. Uncontrollable movements of the face E. Contractures
B, C, E Rationale: The nurse should expect a child who has spastic cerebral palsy to exhibit ankle clonus, which is a rhythmic reflex tremor when the foot is dorsiflexed; The nurse should expect a child who has spastic cerebral palsy to exhibit spasticity or exaggerated stretch reflexes; he nurse should expect a child who has spastic cerebral palsy to exhibit contractures due to the tightening of the muscles.
A nurse is teaching a school-aged child who has a new diagnosis of Type 1 diabetes. Which of the following statements made by the child indicates an understanding of the teaching? A. "I will puncture the pad of my finger when I am testing my blood glucose." B. "I will give myself a shot of regular insulin 30 minutes before I eat breakfast." C. "I will eat a snack of 5 grams of carbohydrates if my blood glucose is low." D. "I will decrease the amount of fluids I drink when I am sick."
B. "I will give myself a shot of regular insulin 30 minutes before I eat breakfast." Rationale: The child should administer regular insulin 30 min before meals so that the onset coincides with food intake.
A nurse is teaching the guardian of a 6-month-old child about carseat use. Which of the following statements from the guardian indicates an understanding of the teaching? A. "I should secure the car seat using lower anchors and tethers instead of the seat belt." B. "I should position the car seat harness 1 inch above my baby's shoulders." C. "I will make sure that the car seat is placed at a 90-degree angle." D. "I will pad my baby's car seat with a blanket for traveling long distances."
A. "I should secure the car seat using lower anchors and tethers instead of the seat belt." Rationale: Lower anchors and tethers, or the LATCH child safety seat system, should be used to secure an infant's car seat in the vehicle. This system provides anchors between the front cushion and the back rest for the car seat. Therefore, if this system is available, the seat belt does not have to be used.
A nurse is receiving change of shift report for four children. Which of the following children should the nurse see first? A. A school-age child who has sickle cell anemia and reports decreased vision in the left eye B. A school-age child who has cystic fibrosis and a frequent nonproductive cough C. A preschooler who has asthma and a peak flow meter reading in the green zone D. An adolescent who has meningitis and reports a sensitivity to lights and noise
A. A school-age child who has sickle cell anemia and reports decreased vision in the left eye Rationale: When using the urgent vs. nonurgent approach to client care, the nurse should determine the priority finding is a report of decreased vision in the left eye. This finding indicates that the child is experiencing a vaso-occlusive crisis and should be reported to the provider immediately. Therefore, the nurse should see this child first.
A nurse is teaching the parents of a school-aged child who has osteomyelitis of the tibia. Which of the following statements by the parents indicated an understanding of the teaching? A. "My child will have a cast until healing is complete." B. "My child will receive antibiotics for several weeks." C. "My child can return to playing sports once they have been discharged." D. "My child needs to be in contact isolation."
B. "My child will receive antibiotics for several weeks." Rationale: The nurse should instruct the parent that the child will receive antibiotic therapy for at least 4 weeks. Surgery might be indicated if the antibiotics are not successful.
A nurse is caring for a preschooler who has been receiving IV fluids via a peripheral IV catheter. When preparing to discontinue the IV fluids and catheter, which of the following actions should the nurse plan to take? (place in order) Remove the tape securing the catheter Turn off the IV pump Occlude the IV tubing Apply pressure over the catheter insertion site
First, the nurse should turn off the IV pump. Next, the nurse should occlude the IV tubing, and then remove the tape securing the catheter. Last, the nurse should apply pressure over the catheter insertion site.
A nurse is teaching the parent of an infant who has the Palvik Harness for the treatment of developmental dysplasia of the hip. The nurse should identify that which of the following statements made by the parents indicates an understanding of the teaching? A. "I should remove the harness at night to allow my infant to stretch her legs." B. "I will need to adjust the straps on the harness once each week." C. "I should apply baby powder to my infant's skin twice daily." D. "I will place my infant'
D. "I will place my infant's diapers under the harness straps." Rationale: To prevent soiling of the harness, the parent should apply the infant's diaper under the straps.
