PEDS ATI practice A

Nurse teaches the guardian of 6 month/old infant about care seat use. Which statements by guardian indicates understanding of teaching?

"I should secure the car seat using lower anchors and tethers instead of the seat belt."

Nurse in ED is caring for toddler with partial thickness burns on right arm. Which actions should the nurse take?

Cleanse the affected area with mild soap and water:

Nurse assesses 4 y/o child at well-child visit. Which developmental milestone should the nurse expect to observe?

Cuts an outlined shape using scissors

School nurse assesses adolescent with multiple burns in various stages of healing. Which behaviors should the nurse ID as possible indication of physical abuse?

Denies discomfort during assessment of injuries

Nurse cares for preschooler receiving IV fluids via peripheral IV catheter. When preparing to discontinue IV fluids and catheter, which actions should the nurse plan to take?

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.

Nurse caring for school age child receiving blood transfusion. Which manifestation should alert the nurse to possible hemolytic transfusion reaction?

Flank pain

Nurse in ED is caring for school age child with appendicitis and rates abd. pain 7/10. Which actions should the nurse take?

Give morphine 0.05 mg/kg IV:

nurse teaching the parent of an infant about ways to prevent SIDS. Which instructions should the nurse include

Give the infant a pacifier at bedtime

Nurse is caring for infant with resp syncytial virus (RSV). Which actions should the nurse implement for infection control?

Have a designated stethoscope in the infant's room

Nurse reviews lab report of school age child experiencing fatigue. Which findings should the nurse recognize as an indication of anemia?

Hematocrit 28%

Nurse teaches parent of preschooler about ways to prevent acute asthma attacks. Which statements by parent indicates understanding of teaching?

I should keep my child indoors when I mow the yard.":

Nurse is teaching school age child with new dx of T1DM. Which statements by child indicates an understanding of teaching?

I will give myself a shot of regular insulin 30 minutes before I eat breakfast.":

Nurse teaching parents of infant with Pavlik harness for tx of hip dysplasia. Nurse should ID which statements by parent indicating understanding of teaching?

I will place my infant's diapers under the harness straps.

Nurse creating POC for infant with epidural hematoma from head injury. Which interventions should the nurse include in plan?

Implement seizure precautions for the infant

Nurse reviews lumbar puncture results of school-age child with suspected bacterial meningitis. Which findings should the nurse ID as an indication of bacterial meningitis?

Increased protein concentration

A nurse is assessing a school-age child immediately postoperative following a perforated appendix repair. Which of the following findings should the nurse expect?

absence of peristalsis

A nurse at an urgent care clinic is assessing an adolescent client who has an upper resp tract infection. Which of the following findings should the nurse recognize as a manifestation of pertussis?

dry, hacking cough

Nurse auscultates lungs of adolescent with asthma. Nurse should ID sound as what?

tachypnea

Nurse prepares to admin an immunization to 4 yo child. Which actions should the nurse plan to take?

Administer the immunization using a 24-gauge needle

Nurse admits a school age child with pertussis. Which actions should the nurse take?

Initiate droplet precautions for the child

Nurse is planning care for school age child in oliguric phase of AKI and has sodium level 129 mEq/L. Which interventions should the nurse include in plan?

Initiate seizure precautions for child

Hospice nurse is caring for preschooler with terminal illness. One parent of patient tells the nurse that they cannot cope anymore and are thinking about moving out of the house. Which statement should the nurse make?

Let's talk about some of the ways you have handled previous stressors in your life.":

Nurse assesses infant with ventricular septal defect. Which findings should the nurse expect?

Loud, harsh murmur:

Nurse caring for 15 y/o client following head injury. Which findings should the nurse ID as indication that child's developing SIADH?

Mental confusion

Nurse teaches parents of school age child with new Dx of osteomyelitis of tibia. Which statements by parent indicates an understanding of teaching?

My child will receive antibiotics for several weeks.

Nurse is preparing to collect sample from toddler for sickle-turbidity test. Which actions should the nurse plan to take?

Perform a finger stick

Nurse assesses school age child with meningitis. Which findings is priority for the nurse to report to HCP?

Petechiae on the lower extremities

Nurse caring for school age child experienced a tonic-clonic seizure. Which actions should the nurse take during the immediate postictal period?

Place the child in a side-lying position

Nurse is providing teaching about play activities for social development to parents of preschooler. Which play activities should nurse recommend for child?

Playing dress-up

Nurse is creating POC for school age child with heart disease and has developed heart failure. Which interventions should the nurse include in plan?

Provide small, frequent meals for the child

Nurse assesses 3 y/o toddler at a well-child visit. Which manifestations should the nurse report to HCP?

Respiratory rate 45/min

A nurse is reviewing the laboratory report of a 7-year-old child who is receiving chemotherapy. Which of the following laboratory values should the nurse report to the provider

The nurse should recognize that a hemoglobin level of 8.5 g/dL is below the expected reference range for a 7-year-old child and should be reported to the provider.

Nurse interviews parent of 18 month old toddler during well-child visit. Nurse should ID which findings that indicates a need to assess toddler for hearing loss?

The toddler received tobramycin during a hospitalization 2 weeks ago

Nurse caring for adolescent with severe abd. pain due to appendicitis. Which location should the nurse ID 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.

Nurse in provider's office prepares to admin immunizations to toddler during well-child visit. Which actions should the nurse plan to take?Exhibit:Tuberculin skin test (TST), Measles, mumps, and rubella (MMR) vaccine, Inactivated influenza vaccine, Diphtheria, tetanus, and pertussis (DTaP) vaccine, RR 24/min, HR 115/min, Temp 36.9° C (98.4° F), Age 15 months, Height 71.1 cm (28 in), Allergies Neomycin (anaphylactic reaction), Caregiver reports rhinitis with clear nasal drainage for 2 days, Occasional nonproductive cough for 2 days, History of asthma

Withhold the measles, mumps, and rubella (MMR) vaccine

Nurse cares for preschooler whose father is going home for a few hours while another relative stays with child. Which statements should the nurse make to explain to child when their father will return?

Your daddy will be back after you eat.

Nurse is providing teaching to parent of infant with diaper dermatitis. Nurse should instruct parent to apply what to the affected areas?

Zinc Oxide

Nurse assesses school age child with peritonitis. Which findings should the nurse expect?

abdominal distension

Nurse provides dietary teaching to parent of school age child with celiac disease. Nurse should recommend parent offer which foods to child?

white rice

Nurse teaches parent of school age child with new prescription for oral nystatin for tx of oral candidiasis. Which instructions should the nurse include?

"Shake the medication prior to administration."

Nurse caring for 15 y/o who's married and scheduled for surgical procedure. Client asks " Who should sign my surgical consent?" Which responses should the nurse make?

"You can sign the consent form because you are married."

A school nurse is preparing to administer atomoxetine 1.2 mg/kg/day PO to a school-age child who weighs 75 lb. Available is atomoxetine 40 mg/capsule. How many capsules should the nurse administer per day? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero

1

Nurse receives change of shift report for 4 children. Which children should nurse see first?

A school-age child who has sickle cell anemia and reports decreased vision in the left eye

School nurse assesses an adolescent with scoliosis. Which findings should the nurse expect?

A unilateral rib hump:

Nurse cares for preschooler scheduled for hydrotherapy tx for wound debridement following burn injury. Which actions should the nurse take prior to procedure?

Administer an analgesic to the child

Nurse in ED is caring for school age child experiencing anaphylacitic reaction. Which priority action should be done by the nurse?

Administer epinephrine IM to the child

Nurse caring for toddler with spastic (pyramidal) cerebral palsy. Which findings should the nurse expect? (SATA)

Ankle clonus, Exaggerated stretch reflexes, Contractures

Nurse is preparing an adolescent for lumbar puncture. Which actions should the nurse take?

Apply topical analgesic cream to the site 1 hr prior to the procedure

Nurse caring for school age child in Buck's traction following a leg fracture 24 hrs ago. Which actions should the nurse take?

Assess peripheral pulses once every 4 hr:

Nurse is planning care for toddler with serum lead 4 mcg/dL. Which actions should the nurse plan to take?

Schedule the toddler for a yearly rescreening:

Nurse cares for adolescent who received kidney transplant. Which findings should the nurse ID as indication adolescent is rejecting the kidney?

Serum creatinine 3.0 mg/dL

Nurse in ED is performing physical assessment on 2 week old male newborn. Which findings is priority for nurse to report to HCP?

Substernal retractions:

Charge nurse in ED is preparing an inservice for a group of newly licensed nurses about manifestations for child maltreatment. Which manifestations should the charge nurse include as potential indications of physical abuse?

Symmetric burns of the lower extremities:

Nurse cares for school age child receiving cefazolin via intermittent IV bolus. Child suddenly develops diffuse flushing skin and angiodema. After discontinuing med infusion, which meds should the nurse admin first?

epinephrine

Nurse caring for toddler experiencing acute diarrhea and moderate dehydration. Which nutritional items should the nurse offer to toddler?

oral rehydration solution

A nurse is caring for a school-age child who is receiving chemotherapy and is severely immunocompromised. Which of the following actions should the nurse take? Screen the child's visitors for indications of infection

potential for an overwhelming infection

A nurse is reviewing the lab report of an infant who is receiving tx for severe dehydration. The nurse should identify that which of the following lab values indicates effectiveness of the current tx?

sodium 140

Nurse gives discharge teaching to parent of child 1 week postop following cleft palate repair. Which members of interprofessional team should the nurse initiate a referral?

speech therapist

Nurse assessing toddler with gastroenteritis and exhibits manifestations of dehydration. Which findings is the nurse's priority?

tachypnea

A nurse is assessing the vital signs of a 10-year-old child following a burn injury. Which of the following clinical manifestations indicate early septic shock?

temp of 39.1