Peds - ATI Practice B Online 2019 - 2023

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

Nurse assesses infant with pneumonia. Which findings is priority for nurse to report to HCP? a. Nasal flaring b. WBC count 11,300/mm3 c. Diarrhea d. Abdominal distension

Nasal flaring - When using the ABC approach to client care, the nurse should determine that the priority finding to report to the provider is nasal flaring. Nasal flaring indicates the infant is experiencing acute respiratory distress. Wrong Answers: WBC count 11,300/mm3 - is above the expected reference range of 5,000 to 10,000/mm3 and indicates infection. However, priority Diarrhea - should report diarrhea because it is a manifestation of pneumonia in infants and indicates the current treatment is not effective. Priority Abdominal distension - should report abdominal distension because it is a manifestation of pneumonia in infants and indicates the current treatment is not effective. priority

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

Denies discomfort during assessment of injuries - The nurse should suspect child maltreatment in the form of physical abuse if the adolescent has a blunted response to painful stimuli or injury.

Nurse assesses school age child with infratentorial brain tumor. Which findings should the nurse ID as manifestation of IICP? a. Hypotension b. Reports insomnia c. Difficulty concentrating d. Tachycardia

Difficulty concentrating - The nurse should identify that irritability, inability to follow commands, and difficulty concentrating are manifestations of IICP due to decreased blood flow within the brain and pressure on the brainstem. Wrong Answers: a. Hypotension - HTN is a late manifestation of IICP due to compression of the brain vessels. b. Reports insomnia - somnolence and lethargy are manifestations of IICP. c. Tachycardia - bradycardia is a late manifestation of IICP.

The nurse is caring for the child 4 days after admission. After reviewing the child's assessment, which of the following findings should the nurse address first? The nurse should first address the client's Select... followed by the client's Select... Drop 1 temperature saturated dressing urine output blood pressure respiratory status

Dropdown 1: Temperature is correct. When using the urgent vs. nonurgent approach to client care, the nurse should determine that an increased temperature is a priority finding, because it can indicate an infection and sepsis. Wound sepsis is most likely to occur between the third and fifth day after a burn. Therefore, the nurse should first address the child's temperature. Dropdown 2: Pain is correct. When using the urgent vs. nonurgent approach to client care, the nurse should determine that an 8 out of 10 pain rating on the FACES scale is a priority finding and should be addressed next. Severe pain impacts the stress response, which can lead to complications and adversely affect healing.

Nurse creating POC for newly-admitted adolescent with bacterial meningitis. How long should the nurse plan to maintain adolescent in droplet precautions? -Until the adolescent is afebrile -For 7 days following admission to the facility -Until the adolescent has a negative blood culture -For 24 hrs following initiation of antimicrobial therapy

For 24 hr following initiation of antimicrobial therapy:- The nurse should plan to maintain the adolescent on droplet precautions for at least 24 hr following initiation of antimicrobial therapy. This practice will ensure that the adolescent is no longer contagious, which protects family members and the personnel caring for the client. Prophylactic antibiotics might be prescribed to individuals who were in close contact with the adolescent.

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.

Give morphine 0.05 mg/kg IV .- 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 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

Increased protein Concentration. - The nurse should identify that an increased protein concentration in the spinal fluid is a finding that can indicate bacterial meningitis.

Nurse caring for newly admitted school age child with hypopituitarism. Which meds should the nurse expect the HCP to prescribe?DesmopressinLuteinizing hormone-releasing hormoneRecombinant growth hormoneLevothyroxine

Desmopressin:- used to treat hyposecretion of ADH.Luteinizing hormone-releasing hormone:- used in the treatment of precocious puberty to slow prepubertal growth in children and in the treatment of advanced prostate cancer in adult clients.ANS: Recombinant growth hormone:- used to treat hypopituitarism, which inhibits cell growth and results in growth failure. The nurse should expect the provider to prescribe this treatment.Levothyroxine:- used to treat various hypothyroid conditions.

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

Flank Pain 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. wrong -Laryngeal edema is an indication of an allergic reaction to the blood transfusion -Distended neck veins are an indication of circulatory overload -Muscle weakness is an indication of an electrolyte disturbance, which is a complication

Nurse is monitoring SpO2 level of an infant using pulse ox. Nurse should secure sensor to which areas on the infant? a. Wrist b. Great toe c. Index finger d. Heel

Great toe:- The nurse should secure the sensor to the great toe of the infant and then place a snug-fitting sock on the foot to hold the sensor in place. The nurse should also check the skin under the sensor site frequently for temperature, color, and the presence of a pulse. Wrong -index finger:- The nurse should secure the sensor to the index finger of a child and then use a self-adhering bandage to hold the sensor in place; however, this site is not recommended for pulse ox of an infant. -wrist or heel - important for the sensor to be positioned in the correct area to obtain an accurate reading. The nurse should avoid placing the sensor on the wrist because this placement will result in an inaccurate reading.

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.

Have a designated stethoscope in the infant's room -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. Wrong -initiate droplet precautions for an infant who has RSV because the virus is spread by direct contact with respiratory secretions. -Palivizumab is used for prophylaxis in at-risk infants and is not used in the treatment of RSV. -reduce the risk of transmission, all health care personnel should remove their gloves prior to leaving the infant's room.

Annual screenings for phenylketonuria are important for which age group? a. newborn b. toddler c. school-age child

a. newborn

reflexes (in a newborn)

• Moro reflex/startle reflex (perform grasp reflex, shoulders raised, then release - baby stretches arms) • Grasp reflex • Routing reflex • Sucking reflex • Walking reflex

Nurse cares for school age child with peripheral edema. Nurse should ID which assessments should be performed to confirm peripheral edema? a. Palpate the dorsum of the child's feet. b. Weigh the child daily using the same scale c. Assess the child's skin turgor d. Observe the child for periorbital swelling

Palpate the dorsum of the child's feet:- The nurse should palpate the dorsum of the feet by pressing the fingertip against a bony prominence for 5 seconds to assess for peripheral edema. Wrong - Weighing the child daily might indicate that the child has retained fluid. - Assessing the child's skin turgor measures the elasticity and mobility of the skin. - Observing the child for periorbital swelling is a method used to assess for generalized edema.

Nurse in ED auscultates lungs of adolescent experiencing dyspnea. Nurse should ID sound as what? a. Wheezes b. Crackles c. Pleural friction rub d. Rhonchi

a. Wheezes - high-pitched, musical or whistling-like sounds heard primarily on expiration as air passes through and vibrates narrowed airways. Wrong answers: b. Crackles - high-pitched, short, and noncontinuous sounds usually heard at the end of inspiration. Crackles occur when air expands deflated alveoli or when the passage of air through small airways is disrupted. c. Pleural friction rub - a loud, rough, grating sound that can be heard during inspiration or expiration. A pleural friction rub occurs when the pleurae are inflamed and the surfaces rub together. d. Rhonchi - low-pitched, continuous sounds that have a snore-like quality and are usually louder during expiration. Rhonchi occur when the larger airways are obstructed.

When assessing a young adult client's musculoskeletal system as part of a comprehensive physical examination. Which of the following findings should the nurse expect? (select all that apply) a. convex thoracic spine posteriorly b. exaggerated lumbar curvature c. concave lumbar spine posteriorly d. exaggerated thoracic curvature e. muscles slight larger on the dominant side

a. convex thoracic spine posteriorly c. concave lumbar spine posteriorly e. muscles slight larger on the dominant side

A nurse is providing anticipatory guidance to the caregivers of a toddler. Which of the following should the nurse include? (select all that apply.) a. develop food habits that will prevent dental caries b. meeting caloric needs results in an increased appetite c. expression of bedtime fears is common d. expect behaviors associated with negativism and ritualism e. annual screenings for phenylketonuria are important

a. develop food habits that will prevent dental caries c. expression of bedtime fears is common d. expect behaviors associated with negativism and ritualism (exhibited by toddlers as they seek autonomy, and associated behaviors should be included in the anticipatory guidance )

Nurse teaches adolescent about how to manage tinea pedis. Which statements by adolescent indicates understanding of teaching? a. "I should buy plastic shoes to wear at the swimming pool." b. "I should wear sandals as much as possible." c. "I should place the permethrin cream between my toes twice daily." d. "I should seal my nonwashable shoes in plastic bags for a couple of weeks."

b. "I should wear sandals as much as possible." - Sandals allow air to circulate around the feet, decreasing perspiration and eliminating the medium for bacteria and fungus to grow. -The nurse should inform the adolescent that wearing sandals, open-toed, or well-ventilated shoes will promote healing of the fungal infection.

A nurse is caring for a client who has a nasogastric tube attached to low intermittent suctioning. The nurse should monitor for which electrolyte imbalance? a. hypercalcemia b. hyponatremia c. hyperphosphatemia d. hyperkalemia

b. hyponatremia -nasogastric losses are isotonic and contain sodium.

A nurse is performing a developmental screening on an 18 m/o. Which of the following should the toddler be able to perform? (select all the apply.) a. build a tower with 6 blocks b. throw a ball overhand c. walk up and down stairs d. stand on one foot for a few sec e. use a spoon without rotation

b. throw a ball overhand e. use a spoon without rotation

Charge nurse prepares to make room assignment for newly admitted school age child. Which considerations is the nurse's priority? a. Length of stay b. Treatment schedule c. Disease process d. Self-care ability

c. Disease process - The transmission of infectious diseases is the greatest risk to this child and other children on the unit. Therefore, the child's disease process is the nurse's priority consideration. Wrong answers: a. Length of stay - some client rooms might be larger, and thus more comfortable for families during long hospitalizations. However, this is not the nurse's priority consideration. b. Treatment schedule - children requiring frequent monitoring and treatment should be assigned a room close to the nurses' station, if possible. However, this is not the nurse's priority consideration. d. Self-care ability - children who require more assistance from nurses or assistive personnel should be assigned a room close to the nurses' station, if possible. However, this is not the nurse's priority consideration.

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

White Rice 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 that sometimes lactose deficiency can be secondary to this disease. Wrong Contain gluten and should be avoided. * Wheat crackers *Rye bread * Barley soup

Nurse in health department is caring for emancipated adolescent with STI and unaccompanied by guardian. Which actions should the nurse take? a. Have the adolescent sign a consent form for treatment. b. Instruct the adolescent to return with a guardian. c. Obtain consent from the adolescent's guardian over the phone d. Treat the adolescent without a consent form

a. Have the adolescent sign a consent form for treatment - The nurse should identify that an emancipated minor can sign the consent form for treatment of an STI or any other form of medical treatment requiring consent.

What assessments in a neurological examination should the nurse perform to test the client's balance? (select all that apply) a. Romberg test b. Heel-to-toe walk c. Snellen test d. Spinal accessory function e. Rosenbaum test

a. Romberg test b. Heel-to-toe walk

A nurse is caring for a client who has a blood sodium level 133 mEq/L and blood potassium level 3.4 mEq/L. The nurse should recognize that which of the following treatments can result in these lab values? a. Three tap water enemas b. 0.9% sodium chloride solution IV at 50 mL/hr c. 5% dextrose with 0.45% sodium chloride solution with 30 mEq of K+ IV at 80 mL/hr d. Antibiotic therapy

a. Three tap water enemas -Results in a decrease in blood sodium and potassium. Tap water is hypotonic, and GI losses are isotnic. This creates an imbalance and solute dilution. Wrong Answers: b. 0.9% sodium chloride is an isotonic solution and will not produce these results c. 5% dextrose w/ 0.45% NaCl is isotonic solution

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 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. Wrong: -Toddler who has acute diarrhea should not drink apple juice because it is high in carbohydrates and osmolarity and low in electrolytes. -A toddler who has acute diarrhea should not eat peanut butter because it is high in carbohydrates and fiber. -A toddler who has acute diarrhea should not consume chicken broth because it is high in sodium and is not nutrient-dense.

Deep-tendon reflexes (DTRs): Achilles

-flex the knee, dorsiflex the foot -strike the tendon above the heel -EXPECTED RESPONSE: plantar flexion of the foot

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."

"Give the infant a pacifier at bedtime." - The nurse should inform the parent that protective factors against SIDS include breastfeeding and the use of a pacifier when the infant is sleeping. wrong -instruct the parent to place the infant in a supine position to sleep -Placing the infant on a large pillow to sleep can increase the risk of suffocation, asphyxiation, and SUID -use a firm mattress and avoid the use of waterbeds, beanbags, or soft mattresses when placing the infant in bed

The nurse is providing discharge teaching to the child and their parent 36 days after admission. Select 6 statements. "I will give my child hydroxyzine to prevent bacterial infection." "I should apply a moisturizer to the scar tissue." "I will use a measured spoon or medicine cup to give my child hydroxyzine." "I can give my child hydroxyzine every 6 hours as needed." "Puppet play can be helpful for my child." "I should avoid giving hydroxyzine at bedtime." "I will avoid massaging the scar tiss

"I should apply a moisturizer to the scar tissue" is correct. Frequent application of a non-perfume moisturizer should be applied to the scar tissue to help reduce itching "I will use a measured spoon or medicine cup to give my child hydroxyzine" is correct. All liquid medications should be administered with a measured spoon or cup to provide an accurate amount "I can give my child hydroxyzine every 6 hours as needed" is correct. Hydroxyzine administered every 6 to 8 hr as needed. "Puppet play can be helpful for my child" is correct. Preschoolers engage in imaginative play. The use of puppets will encourage the child to express their feelings "I need to assess for any redness or open skin areas before applying my child's left arm splint" is correct. It is important that the child's skin be assessed for redness, open areas, or blisters prior to putting on a splint. The splint is used to prevent contractures of the extremities and promote normal alignment during the healing process.

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."

"I will give myself a shot of regular insulin 30 minutes before I eat breakfast."- The child should administer regular insulin 30 min before meals so that the onset coincides with food intake.

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. 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. "Let's talk about some of the ways you have handled previo

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

A unilateral rib hump - 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.

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.

Administer the immunization using a 24-gauge needle. - 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 in an emergency department is caring for a 4-year-old child who was rescued from a home fire by emergency medical services (EMS). Which of the following potential provider prescriptions should the nurse identify as anticipated or contraindicated? a. Apply sterile gauze soaked with cool 0.9% sodium chloride to the burn areas. b. Insert an indwelling urinary catheter. c. Provide 100% oxygen via face mask. d. Weigh the child.

Apply sterile gauze soaked with cool 0.9% sodium chloride to the burn areas is contraindicated. Applying sterile gauze soaked with cool 0.9% sodium chloride to a child who has 18% TBSA might cause hypothermia. cover the burn with a clean, dry cloth to prevent contamination and hypothermia. Insert an indwelling urinary catheter is anticipated. allows for accurate measurement of urine output. A child who has major burns will lose a significant amount of fluid due to increased capillary permeability, which increases the risk for hypovolemic shock. Provide 100% oxygen via face mask is anticipated. recognize the need to provide 100% oxygen via face mask as an essential prescription. The child's SaO2 is below the expected reference range and their respiratory rate is increased. Weigh the child is anticipated. weigh the child as essential. The amount of fluid resuscitation and medication a pediatric patient receives is based on their weight.

The nurse is continuing to care for the child. After examining the child during hydrotherapy, the provider enters prescriptions into the child's medical record. For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the child. Change the morphine route to family-controlled analgesia via a PCA pump. Obtain a wound culture. Place the child on a pressure-reduction mattress. Limit daily protein intake.

Change the morphine route to family-controlled analgesia via a PCA pump is anticipated. A pain rating of 8 indicates severe pain. The use of a PCA pump should increase the effectiveness of pain management during movement and procedures. The nurse should teach the child's primary caregiver about the use of the PCA pump. Obtain a wound culture is anticipated. The child has an elevated temperature and malodorous green wound drainage. The nurse should obtain a wound culture to determine the causative organism and an antibiotic should be administered. Place the child on a pressure-reduction mattress is anticipated. The child has developed a stage 1 pressure injury on their occiput. A pressure-reduction mattress can help prevent further tissue injury. Limit daily protein intake is contraindicated. Children who have major burns require a high-protein, high-calorie diet to help with wound healing. The nurse should provide high-protein snacks to the child between meals.

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.

Cleanse the affected area with mild soap and water. - The nurse should wash the affected area with mild soap and water to remove any loose tissue that could cause infection

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

Epinephrine: 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.

The nurse is caring for the child 14 days after admission. The child has returned to the unit following the procedure. Which of the following actions should the nurse take? Select all that apply. 0800: Surgical placement of permanent skin graft of the anterior neck and left anterior chest Child is difficult to arouse. Arouses to repeated loud noise and moderate tactile stimulation Respirations are unlabored and very shallow. Breath sounds are clear and equal bilaterally. No cyanosis Neck and l

Monitor SaO2 every 2 hr is incorrect. The nurse should continuously monitor the child's SaO2 until it is stable. Provide 100% oxygen via face mask is correct. The nurse should provide 100% oxygen via face mask to the child because of their SaO2 and respiratory rate. The SaO2 should be maintained at 95% or higher Check anterior neck and chest dressing for bleeding is correct. Upon return from the procedure, all surgical dressings should be assessed for drainage/ intact Replace the dressing on the left thigh is incorrect. The nurse should not remove the dressing from the left thigh. Surgical dressings should not be removed from the donor site (left thigh) to avoid damage fragile epithelium. Place a warm blanket on the child is correct. exhibiting hypothermia. It is important have a stable body temperature because vasoconstriction can diminish blood flow to surgical sites and impair healing. Keep the child's head in a neutral position is correct. The child's head should be kept in a neu

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.

Perform a finger stick : 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. Wrong -Sputum specimens are collected to identify the infectious organism -Allen test determines adequate circulation by observing capillary refill before an arterial puncture -stool specimens are collected to identify organisms or parasites that cause diarrhea or to check for the presence of occult blood.

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

Petechiae on the lower extremities - 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 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.

Place the child in a side-lying position. - The nurse should place the child in a side-lying position to prevent aspiration.

A nurse in an emergency department is caring for a 4-year-old child who was rescued from a home fire by emergency medical services (EMS). Child has partial-thickness and full-thickness burns on their left arm, hand, anterior neck, and upper left side of the anterior chest. Total body surface area (TBSA) estimated to be 18%. Child is awake and crying. Lungs are clear bilaterally. Has a non-productive cough. 3 findings that require immediate follow-up.

Select the 3 findings that require immediate follow-up. Partial- and full-thickness burns to the left upper anterior chest and anterior neck is correct. Airway, breathing, and circulation are the immediate concerns. Burns to the chest and neck require immediate follow-up due to a concern for inhalation injury. In addition, the edema of the tissue in the neck can compromise the airway and severe burns to the chest can impede the child's ability to expand their chest during inspiration, causing respiratory distress. SaO2 89% on room air is correct. The nurse should immediately follow-up on the low oxygen saturation level. Hypoxia can be a manifestation of respiratory distress or shock. Therefore, this finding needs immediate attention. Heart rate 150/min is correct. The nurse should immediately follow-up on the child's increased heart rate. Tachycardia is a manifestation of shock. Children with major burns can develop hypovolemic shock due to fluid loss.

Nurse teaching parents of toddler with cognitive impairment about toilet training. Which instructions should the nurse include in teaching? a. "Scold your child when they have a toileting accident." b. "Award your child with a sticker when they sit on the potty chair." c. "Play your child's favorite song while teaching them to use the potty chair." d. "Teach multiple steps of the skill at the same time."

"Award your child with a sticker when they sit on the potty chair.":- A child who has a cognitive impairment learns through shaping behaviors. The parents should reward the child for sitting on the potty chair as a reinforcement of the desired behavior of continence. As the child repeats this action, the parents can gradually decrease this reward and then give rewards for the next step in the task, such as voiding while sitting on the potty chair.

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."

"I should secure the car seat using lower anchors and tethers instead of the seat belt." - 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. Wrong -car seat harness in rear-facing car seats should be positioned at or just below the infant's shoulders. -should be positioned at a 45° angle to prevent slumping and injury to the infant. -Padding placed underneath the infant or anywhere in the car seat can compress and/or create space between the infant and the harness. This can increase the risk for injury

Nurse teaching group of parents about infectious mononucleosis. Which statements by parent indicates understanding of teaching? -"Mononucleosis is caused by an infection with the Epstein-Barr virus." -"Mononucleosis is a bacterial infection requiring 14 days of antibiotics." -"A Monospot is a throat culture used to diagnosis mononucleosis." -"Children who get mononucleosis will need to refrain from sports for 6 months."

"Mononucleosis is caused by an infection with the Epstein-Barr virus.":- The nurse should identify that mononucleosis is a mildly contagious illness that occurs sporadically or in groups, and is primarily caused by the Epstein-Barr virus. Wrong -"Mononucleosis is a bacterial infection requiring 14 days of antibiotics.":- No known specific treatment available for mononucleosis. -the nurse should identify that a Monospot is a blood test that uses a special piece of paper to assist in diagnosing mononucleosis. -"Children who get mononucleosis will need to refrain from sports for 6 months.":- child who has mononucleosis should adjust their activities according to their level of fatigue. It is recommended that contact sports be avoided for about 4 weeks, or until splenomegaly has resolved.

A nurse in a provider's office is caring for a preschooler. Which statement indicate that discharge teaching was effective? Select all that apply. "We should apply a skin emollient immediately after bathing our child." "We should keep our child's fingernails trimmed short." "We should rub the sores vigorously to remove scabs." "We should allow our child to take a bubble bath prior to bed." "We should use a mild detergent for our laundry." "We should apply a large amount of the ointment to the ar

"We should apply a skin emollient immediately after bathing our child" is correct. An emollient is an oil that moisturizes the skin and applied immediately after bathing, while the skin is damp, to prevent drying. "We should keep our child's fingernails trimmed short" is correct. The child's fingernails and toenails should be kept short, trimmed, and filed to prevent scratching with sharp edges. "We should use a mild detergent for our laundry" is correct. The use of mild detergents for laundry helps prevent allergens and itching. "We should rub the sores vigorously to remove scabs" is incorrect. The sores/lesions should be patted dry after bathing, rather than scrubbed vigorously. The scabs should not be removed could cause infection. "We should allow our child to take a bubble bath prior to bed" is incorrect. The use of bubble baths should be avoided they can cause skin irritation. "We should apply a large amount of the ointment to the sores" is incorrect. Tacrolimus is a topical

Nurse in HCP office is caring for school age child with varicella. Parent asks nurse when their child will no longer be contagious. Which response should the nurse make? a. "When your child no longer has an increased temperature." b. "Three days after you first noticed the rash appear on your child." c. "When your child's lesions are crusted, usually 6 days after they appear." d. "Two to three weeks, when your child's lesions completely disappear."

"When your child's lesions are crusted, usually 6 days after they appear.":- The nurse should inform the parent that the child is contagious 1 day prior to lesion eruption and until the vesicles have crusted over, which usually takes about 6 days. Wrong - The nurse should inform the parent that an absence of a fever does not indicate the child is no longer contagious. - The nurse should inform the parent that the child will remain contagious longer than 3 days after the rash appears. - The incubation period of varicella is two to three weeks. However, this is not related to the appearance and disappearance of the lesions.

Deep-tendon reflexes (DTRs): Biceps

-flex arm 45 degrees -place the thumb on the tendon in antercubital fossa -strike thumb with a reflex hammer -EXPECTED RESPONSE: flexion of the elbow

Deep-tendon reflexes (DTRs): Brachioradialis

-rest a forearm on the examiner's forearm with the wrist slightly pronated -strike the tendon 2.5 to 5 cm above the wrist -EXPECTED RESPONSE: pronation of the forearm and flexion of the elbow

Deep-tendon reflexes (DTRs): Triceps

-support the upper arm with the forearm handing at a 90 degree angle -strike the tendon above the elbow -EXPECTED RESPONSE: extension of the elbow

Deep-tendon reflexes (DTRs): Patellar

-witht he upper leg supported and the lower leg dangling freely -strike the tendon below the knee -EXPECTED RESPONSE: extension of the lower leg

A nurse is preparing to administer ibuprofen 5mg/kg every 6 hours prn for temperatures above 38.0 C (100.5 F) to an infant that weighs 17.6 Lb. The infant has a temperate of 38.4 C (101.2 F). Available is ibuprofen liquid 100mg/5mL. How many mL should the nurse administer to the infant per dose? round to the nearest whole number. Use a leading 0 if it applies.

2 mL

Deep-tendon reflexes (DTRs) are graded as...

4+ = ver brisk with clonus 3+ = more brisk than average 2+ = expected 1+ = diminished 0 = no response

Nurse in ED is caring for school age child with sustained minor superficial burn from fireworks on forearm. Which actions should the nurse take? a. Administer the tetanus toxoid vaccine if more than 1 year since the prior dose. b. Apply an antimicrobial ointment to the affected area. c. Leave the burn area open to air. d. Place an ice pack on the affected area.

Apply an antimicrobial ointment to the affected area:- The nurse should apply an antimicrobial ointment to the burned area to prevent infection. wrong -Administer the tetanus toxoid vaccine if more than 1 year since the prior dose:- administer the tetanus toxoid vaccine if it has been more than 5 years since the prior dose. -Leave the burn area open to air:- apply a clean-dry dressing of fine mesh gauze and a light gauze dressing that restricts movement to prevent injury to the wound. -Place an ice pack on the affected area:- Applying ice to the affected area can impair circulation to the area and increase tissue damage.

School nurse is caring for child following tonic-clonic seizure. Which actions should the nurse take first? Check the child for a head injury. Observe for oral bleeding. Check the child's respiratory rate. Observe for extremity weakness.

Check the child's respiratory rate:- When using the ABC approach to client care, the nurse should determine the priority action is to assess the child's RR. If the child is not breathing, the nurse should administer rescue breaths.

A nurse is caring for a toddler. Toddler brought to office report of cough that won't go away and recurring respiratory infections. States toddler has been coughing past several weeks with wheezing starting overnight. Respirations labored; rhonchi auscultated. Nasal congestion noted. Child is lethargic/irritable. States toddler is "often sweaty, and when I kiss them, it tastes salty." States the child has been eating well prior to today but won't gain weight. Loose, fatty stool in diaper.

Complete the diagram by dragging from the choices below to specify what condition the client is most likely experiencing, 2 actions the nurse should take to address that condition, and 2 parameters the nurse should monitor to assess the client's progress. Actions to Take Prepare toddler for chest physiotherapy. Educate guardian about sweat chloride testing. Potential Condition Cystic Fibrosis Parameters to Monitor Oxygen saturation level Stools

Nurse planning care for newly admitted school-age child with generalized seizure disorder. Which interventions should the nurse plan to include? -Ensure that a padded tongue blade is at the child's bedside. -Allow the child to play video games on a tablet computer. -Allow the child to take a tub bath independently. -Ensure the oxygen source is functioning in the child's room.

Ensure the oxygen source is functioning in the child's room. The nurse should recognize that maintaining the child's airway is important during a seizure. Ensure that the oxygen source is functioning because the child might require supplemental oxygen following a seizure. Nothing should be placed in the child's mouth during or after a seizure. Bright or flashing lights from video games can trigger seizure activity. Decrease environmental stimuli and offer other play activities, such as reading a book or playing with a stuffed animal. The nurse should allow the child to take a tub bath with supervision, but not independently. There should be someone available to assist the child if they experience a seizure.

Nurse is reviewing lab results of a school age child 1 week postop following an open fracture repair. Which findings should nurse ID as indication of potential complication? a. Erythrocyte sedimentation rate 18 mm/hr b. WBC count 6,200/mm3 c. C-reactive protein 1.4 mg/LRBC count 4.7 million/mm3 d. RBC count 4.7 million/mm3:

Erythrocyte sedimentation rate 18 mm/hr - above the expected reference range of up to 10 mm/hr and is an indication of osteomyelitis. Wrong Answers: WBC count 6,200/mm3:- within the expected reference range of 5,000 to 10,000/mm3. C-reactive protein 1.4 mg/L:- within the expected reference range of <10.0 mg/L. Elevated C-reactive protein indication of osteomyelitis. RBC count 4.7 million/mm3:- within the range of 4.0 to 5.5 million/mm3.

A nurse is assessing a client who has hyperkalemia. The nurse should identify what condition as being associated with this electrolyte imbalance? a. Diabetic ketoacidosis b. Heart failure c. Cushing's syndrome d. Thyroidectomy

a. Diabetic ketoacidosis Wrong answers: b. Heart failure is associated with hyponatremia c. Cushing's syndrome is associated with hypernatremia

Nurse gives anticipatory guidance to parent of toddler. Which expected behavior characteristics should the nurse include? -Controls impulsive feelings -Understands right from wrong -Easily separates from parents for long periods of time -Expresses likes and dislikes

Expresses likes and dislikes Controls impulsive feelings:- an expected behavior of school-age children. A toddler is more likely to have difficulty controlling strong and impulsive feelings as they try to assert their independence and gain control of situations.Understands right from wrong:- Understanding right from wrong and modifying their behavior in response to others' expectations is an expected behavior of preschoolers. Toddlers tend to have a great deal of curiosity and ask many questions but are not able to fully understand what behaviors are right or wrong.Easily separates from parents for long periods of time:- A toddler might be able to separate from their parents for a short period of time, but the toddler is more likely to experience acute separation anxiety when separated from their parents for an extended period of time. The toddler might offer resistance if they are left with a new babysitter or at a new day care center.

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

Hgb 8.5 g/dL - 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. Wrong -receiving chemotherapy is at risk for infection due to the myelosuppressing effects of the medication used to treat the cancer. The presence of infection can be evaluated through body temperature, redness, edema, warmth, or drainage of wound or IV sites, as well as through measurements of WBC and absolute neutrophil counts -prealbumin level of 18 mg/dL is within the expected reference range of 15 to 33 mg/dL for a 7-year-old child. -platelet count of 300,000/mm3 is within the expected reference range of 150,000 to 400,000/mm3 for a 7-year-old child.

Nurse is planning care to address nutritional needs for preschooler with cystic fibrosis. Which interventions should the nurse include in plans? a. Administer pancreatic enzymes 2 hr after meals. b. Discontinue the use of pancreatic enzymes if steatorrhea develops. c. Limit fluid intake to 750 mL per day. d. Increase fat content in the child's diet to 40% of total calories.

Increase fat content in the child's diet to 40% of total calories - A child who has cystic fibrosis is unable to properly digest fats due to fibrosis of the pancreas and limited secretion of pancreatic enzymes. The nurse should increase the child's fat intake to 35% to 40% of total caloric intake. Wrong Answers: - The nurse should plan to administer pancreatic enzymes within 30 min of meals and snacks to replace the enzymes lost with cystic fibrosis. - A child who has cystic fibrosis and develops steatorrhea, or fatty stools, might need to have their dosage of pancreatic enzyme increased by their provider until the steatorrhea resolves. - The nurse should encourage fluid intake, rather than restrict it, to prevent dehydration caused by the loss of sodium and chloride through perspiration.

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

Loud, harsh murmur - 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. Wrong -Ventricular septal defect does not affect the electrical conduction of the heart -weak femoral pulses when assessing an infant who has coarctation of the aorta. -expect an elevated blood pressure when assessing an infant who has coarctation of the aorta.

A nurse is caring for a preschool-age child. Exhibit 1. For each assessment finding, click to specify if the finding is consistent with nightmares, sleep terrors, or insomnia. Each finding may support more than 1 disease process. Child's responsiveness to guardian Child's description of the dream Child's concentration Timing of child's crying Impulsivity Daytime alertness Child's return to sleeping

Manifestations of nightmares -awaken during the night scary dream. Sleep disturbances that cause distress after dream is over. -The child might be crying, fearful of returning to sleep, believe dream is real. -Sleep disturbances cause interruptions in sleep-wake cycle concentration, daytime fatigue, and impulsive behaviors. Manifestations of sleep terrors -partial awaken during deep sleep. Sleep disturbances that cause child to exhibit behaviors such as thrashing, screaming, moaning, and diaphoresis disappear once child awakens. -The child does not remember the episode and is not comforted by others during the disturbance. -The child usually falls asleep easily afterwards. -Sleep terrors interruptions in sleep-wake cycle impaired concentration, daytime fatigue, and impulsive behaviors. Manifestations of insomnia -difficulty falling or staying asleep - feeling tired when waking up. - Insomnia sleep disorder that causes an inability to sleep, imbalance in the sleep-wake cycle im

Nurse planning developmental activities for newly admitted 10 y/o child with neutropenia. Which actions should the nurse plan to take? -Provide the child with a book about adventure. -Arrange frequent visits from family members and peers. -Give the child a large-piece puzzle. -Use puppets to entertain the child.

Provide the child with a book about adventure The nurse should provide a school-age child with a book about adventure as a developmental activity because children are expanding their knowledge and imagination during this age. Through reading, school-age children can feel powerful and skillful as they imagine themselves in the stories they read. Wrong puppets to entertain toddlers large-piece puzzle to a preschooler. School-age children tend to be challenged mentally with complex board and video games.

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

Respiratory rate 45/min - 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. Wrong -blood pressure of 90/50 mm Hg is within the expected reference range of 86 to 118 mm Hg systolic and 44 to 74 mm Hg diastolic for a 3-year-old toddler. -weight of 14.5 kg (32 lb) is the average weight for a 3-year-old toddler. -heart rate of 110/min is within the expected reference range of 80 to 120/min for a 3-year-old toddler.

Nurse caring for 1 month old infant who's breastfeeding and requires heel stick. Which actions should the nurse take to minimize infant's pain?Use a manual lancet to obtain the heel blood sample.Apply an ice pack to the infant's heel prior to obtaining the sampleAllow the mother to breastfeed while the sample is being obtained.Apply a topical lidocaine cream prior to obtaining the sample

Use a manual lancet to obtain the heel blood sample:- The use of a manual lancet should be avoided because it can cause more discomfort. EBP recommends using an automatic lancet to obtain heel samples because it is safer and less traumatic.Apply an ice pack to the infant's heel prior to obtaining the sample:- The nurse should apply a heating pad to the infant's heel prior to obtaining the sample. This will increase blood flow to the site, which will make the sample easier to obtain.ANS: Allow the mother to breastfeed while the sample is being obtained:- The nurse should allow the mother to breastfeed the infant prior to or during the procedure. EBP indicates breastfeeding or non-nutritive sucking with a pacifier can provide nonpharmalogical pain management in infants.Apply a topical lidocaine cream prior to obtaining the sample:- The use of topical lidocaine is not an effective pain management technique for a heel stick.

A nurse is assessing a client for Chvostek's sign. Which of the following techniques should the nurse use to perform this test? a. apply a blood pressure cuff b. place the stethoscope bell over the clients carotid artery c. tap lightly on the client's cheek d. ask the client to lower their chin to their chest

c. tap lightly on the client's cheek -tap over the facial nerve just below and anterior to the ear to elect Chvostek's sign. A positive response = facial twitching on this side of the face Wrong answers: d. asking the client to lower their chin to their chest is performed to assess ROM of the neck

A nurse is providing teaching about age-appropriate activities to the guardian of a 2 y/o. Which statement by the guardian indicates an understanding of the teaching? a. "I will send my child's fav stuffed animal when napping away from home will occur" b. "my child should be able to stand on one foot for a second" c. "the soccer team my child will be playing on starts practicing next week" d. "I should expect my child to be able to draw circles"

"I will send my child's fav stuffed animal when napping away from home will occur" - transitional objects (fav stuffed animal) provide a sense of security for toddlers Wrong answers: d. "I should expect my child to be able to draw circles" - this requires good fine motor coordination. drawing circles is appropriate for a 2 1/2 year old child

Nure gives discharge teaching to guardian of school age child who's undergone tonsillectomy. Which statements by guardian indicates understanding of teaching?"My child can resume usual activities since this was just an outpatient surgery.""My child will be able to drink the chocolate milkshake I promised to get for them tonight.""I will notify the doctor if I notice that my child is swallowing frequently.""I will have my child gargle with warm salt water to relieve their sore throat."

"My child can resume usual activities since this was just an outpatient surgery.":- Activity should be limited following a tonsillectomy to decrease the risk of hemorrhage."My child will be able to drink the chocolate milkshake I promised to get for them tonight.":- Milk products should be avoided because they coat the child's throat, which can initiate a cough response and increase the risk of bleeding. Brown and red foods should be avoided during the immediate postoperative period so that food and fresh or old blood are distinguishable in the child's emesis.ANS: "I will notify the doctor if I notice that my child is swallowing frequently.":- The nurse should instruct the parent that frequent swallowing is an indication of bleeding and, if it is observed, to notify the provider immediately."I will have my child gargle with warm salt water to relieve their sore throat.":- Gargles are likely to cause irritation and discomfort and can increase the risk of bleeding following a tonsillecto

Nurse receiving change of shift report for 4 children. Which children should the nurse assess first? a. A toddler who has a concussion and an episode of forceful vomiting b. An adolescent who has infective endocarditis and reports having a headache c. An adolescent who was placed into halo traction 1 hr ago and reports pain as 6 on a scale of 0 to 10 d. A school-age child who has acute glomerulonephritis and brown-colored urine`

A toddler who has a concussion and an episode of forceful vomiting:- When using the urgent vs. nonurgent approach to client care, the nurse should assess this child first. An episode of forceful vomiting is an indication of IICP in a toddler who has a concussion. wrong -An adolescent who has infective endocarditis and reports having a headache:- A report of a headache is nonurgent because it is an expected finding for a child who has infective endocarditis. -An adolescent who was placed into halo traction 1 hr ago and reports pain as 6 on a scale of 0 to 10:- A report of moderate pain is nonurgent. -A school-age child who has acute glomerulonephritis and brown-colored urine:- Brown-colored urine is nonurgent it is an expected finding for a school-age child who has acute glomerulonephritis.

Nurse performs hearing screenings for children at community health fair. Which children should the nurse refer to HCP for more extensive hearing evaluation? -An 18-month-old toddler who has unintelligible speech -A 3-month-old infant who has an exaggerated startle response -A 4-year-old preschooler who prefers playing with others rather than alone -An 8-month-old infant who is not yet making babbling sounds

An 18-month-old toddler who has unintelligible speech:- The nurse should refer a toddler who does not possess intelligible speech by the age of 24 months to a provider for a more extensive evaluation of hearing.A 3-month-old infant who has an exaggerated startle response:- The nurse should refer infants who are under the age of 4 months and lack a startle response to a provider for a more extensive evaluation of hearing.

A nurse on a pediatric unit is caring for a school-age child. Select the 4 findings report to the provider. Child appears restless. Moderate intercostal retractions noted. Scattered rhonchi anterior bases with wheezing noted on inhalation and exhalation. Point of maximum intensity (PMI) in the left mid-clavicular line 4th intercostal space. Heart rate is regular without murmurs, gallops, or rubs. Radial and pedal pulse 2+ bilaterally. Arterial blood gas Cardiovascular assessment WBC Count Hemogl

Arterial blood gases is correct. (ABGs) indicate respiratory alkalosis, which is associated with complications of asthma, such as hyperventilation and hypoxia. WBC count is correct. WBC count is above the expected reference range, which could be an indication of infection or inflammation. Oxygen saturation level is correct. The child's oxygen saturation level has decreased below the expected reference range despite the use of supplemental oxygen. Respiratory assessment is correct. The child's respiratory assessment indicates increased respiratory distress, as evidenced by the presence of tachypnea, retractions, and increased wheezing. Cardiovascular assessment is incorrect. The child's cardiovascular assessment reflects expected findings for a school-age child. Hemoglobin is incorrect. The child's hemoglobin is within the expected reference range.

A nurse is assessing a 2 1/2 y/o toddler at a well-child visit. Which of the following findings should the nurse report to the provider? a. height increased by 7.5 cm (3 in) in the past year b. Head circumference exceeds chest circumference c. anterior and posterior fontanels are closed d. current weight equals four times the birth weight

Head circumference exceeds chest circumference - head and chest circumference should be equal by 1-2 years of age, with the chest circumference continuing to increase in size until it exceeds the head circumference.

Nurse caring for 10 y/o following head injury. Which findings should the nurse ID as an indication that the child is developing diabetes insipidus? -Urine specific gravity 1.045 -Sodium 155 mEq/L -Blood glucose 45 mg/dL -Urine output 35 mL/hr

Sodium 155 mEq/L:- A child who has a head injury can develop diabetes insipidus as a result of pituitary hypofunction leading to a deficiency of ADH. Under-excretion of ADH leads to polyuria and polydipsia, and possibly dehydration. With the excessive loss of free water, sodium levels rise above the expected reference range of 136 to 145 mEq/L. Wrong -Blood glucose 45 mg/dL:- below the expected reference range of 70 to 110 mg/dL. A child who has diabetes insipidus is within the expected reference range. -Urine output 35 mL/hr:- within the expected reference range of 33 to 58 mL/hr for a 10-year-old child. A child who has diabetes insipidus is expected to have polyuria. -Urine specific gravity 1.045:- above the expected reference range of 1.005 to 1.030. A child who has diabetes insipidus is more likely to have diluted urine and a urine specific gravity below the expected reference range.

Nurse planning care for school age child with tunneled CVA device. Which interventions should the nurse include in plan? a. Use sterile scissors to remove the dressing from the site. b. Irrigate each lumen weekly with 10 mL of 0.9% sodium chloride solution when not in use c. Access the site using a noncoring angled needle d. Use a semipermeable transparent dressing to cover the site

Use a semipermeable transparent dressing to cover the site - The nurse should cover the site with a semipermeable transparent dressing to reduce the risk of infection. Wrong Answers: a. Use sterile scissors to remove the dressing from the site - avoid the use of scissors when performing dressing changes because this can result in accidental cutting of the catheter. b. Irrigate each lumen weekly with 10 mL of 0.9% sodium chloride solution when not in use - flush each lumen of the catheter with a heparin solution daily when not in use. c. Access the site using a noncoring angled needle - should use a noncoring angled or straight needle accessing an implanted port.

A nurse is collecting data from an older adult client as part of a neurological examination. Which findings should the nurse expect as changeds associated with aging? (select all that apply) a. slower light touch sensation b. some vision and hearing decline c. slower fine finger movement d. some short-term memory decline e. decreased risk of depression

a, b, c, d

Nurse teaches family of school age child with juvenile idiotpathic arthritis. Which instructions should the nurse include in teaching?"Limit movement of the child's large joints.""Encourage the child to perform independent self-care.""Provide the child with a soft mattress for sleeping.""Schedule a 2-hour daily nap for the child in the afternoon."

"Limit movement of the child's large joints.":- Large joints should be exercised regularly to maintain mobility and strengthen muscles.ANS: "Encourage the child to perform independent self-care.":- The nurse should teach the family the importance of encouraging the child to perform independent self-care. This will minimize the child's pain while maximizing mobility. Encouraging and praising the child's efforts for independence will also increase their self-esteem."Provide the child with a soft mattress for sleeping.":- Children who have juvenile idiopathic arthritis should sleep on a firm mattress to provide support in maintaining joints in a functional position."Schedule a 2-hour daily nap for the child in the afternoon.":- Daytime naps are discouraged because stiffness can occur quickly and easily with inactivity, and naps can interfere with nighttime sleep

Nurse gives discharge teaching to parents of 3 month old infant following cheiloplasty. Which instructions should the nurse include?"Clean your baby's sutures daily with a mixture of chlorhexidine and water.""Expect your baby to swallow more than usual over the next few days.""Inspect your baby's tongue for white patches using a tongue depressor every 8 hours.""Apply a thin layer of antibiotic ointment on your baby's suture line daily for the next 3 days."

"Clean your baby's sutures daily with a mixture of chlorhexidine and water.":- The nurse should instruct the parents to clean the infant's sutures with sterile water or diluted hydrogen peroxide."Expect your baby to swallow more than usual over the next few days.":- The nurse should instruct the parents to notify the provider of excessive swallowing because this can indicate bleeding and the infant's swallowing of the blood."Inspect your baby's tongue for white patches using a tongue depressor every 8 hours.":- The nurse should instruct the parents to avoid placing objects, such as tongue depressors, in the infant's mouth to prevent injury to the suture line.ANS: "Apply a thin layer of antibiotic ointment on your baby's suture line daily for the next 3 days.":- The nurse should instruct the parents to apply a thin layer of antibiotic ointment on the infant's suture line daily for 3 days and then continue to apply petroleum jelly to the area for several weeks to promote healing.

Nurse reviews dietary choices of adolescent with iron deficiency anemia. Nurse should ID which menu items has highest amount of nonheme iron?½ cup whole milk1 cup orange juice1/2 cup raisins1 cup raw carrots

ANS: ½ cup raisins:- The nurse should encourage the adolescent to eat raisins because they contain the highest amount of nonheme iron. 1 cup orange juice:- Orange juice does not contain the highest amount of nonheme iron. However, it does contain ascorbic acid, which increases the amount of nonheme iron absorbed by the body.

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

Abdominal distention: 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. Wrong -Hypoactive bowel sounds are a manifestation of peritonitis -Tachycardia is a manifestation of peritonitis -Bloody stool is a manifestation of Meckel diverticulum, not peritonitis

Nurse is caring for toddler with acute otitis media and temp of 40 C (104 F). After admin acetaminophen, which actions should the nurse plan to take to reduce toddler's temp? a. Apply a cooling blanket to the toddler. b. Dress the toddler in minimal clothing. c. Give the toddler a tepid bath. d. Administer diphenhydramine to the toddler.

Dress the toddler in minimal clothing The nurse should recognize that dressing the toddler in minimal clothing will expose the skin to air and maximize heat evaporation from the skin, thus reducing the toddler's temperature. Applying a cooling blanket can cause shivering and discomfort, which increases metabolic requirements. The nurse should be aware that the use of a cooling blanket is indicated for the treatment of hyperthermia, but not a fever. The nurse should be aware that the use of a tepid bath is indicated for the treatment of hyperthermia, but not a fever. Diphenhydramine is an antihistamine indicated for the treatment of an allergic reaction.

Nurse in ED assesses toddler with Kawasaki disease. Which findings should the nurse expect? (SATA) a. Increased temperature b. Gingival hyperplasia c. Xerophthalmia d. Bradycardia e. Cervical lymphadenopathy

Increased temperature is correct:- Kawasaki disease is an acute illness associated with a fever that is unresponsive to antipyretics or antibiotics. Cervical lymphadenopathy is correct:- A child can develop enlarged cervical nodes on one side of the neck that are nontender and greater than 1.5 cm in size Xerophthalmia is correct:- Ophthalmic manifestations of Kawasaki disease include reddening of the conjunctiva and dryness of the eyes, or xerophthalmia. Wrong Gingival hyperplasia is incorrect:- Children who have Kawasaki disease develop a strawberry tongue, cracked lips, and edema of the oral mucosa and pharynx. A child who is receiving phenytoin therapy can develop gingival hyperplasia. Bradycardia is incorrect:- Kawasaki disease is an infection that affects the vascular system, including the heart. The nurse should expect the child to be tachycardic with a gallop rhythm. Long-term effects of Kawasaki disease include the development of coronary artery a

Nurse gives discharge teaching to guardians of toddler with lower leg cast applied 24 hrs ago. Nurse should instruct guardians to report which findings to HCP? a. Capillary refill time less than 2 seconds b. Restricted ability to move the toes c. Swelling of the casted foot when the leg is dependent d. Pedal pulse +3 bilateral

Restricted ability to move the toes:- The nurse should inform the guardians that a restricted ability of the toddler to move their toes is an indication of neurovascular compromise and requires immediate notification of the provider. Permanent muscle and tissue damage can occur in just a few hours. wrong -Capillary refill assessed to determine circulatory status by pressing lightly on the tips of the toes until the skin has blanched. time that is > 2 seconds indicates circulatory compromise and should be reported to the provider ASAP. - Swelling of the casted foot when the leg is dependent:- an expected finding. frequent rest is needed for the next several days, and that the casted foot should not be in a dependent position for more than 30 min. -When the toddler is resting, the casted extremity should be elevated on a pillow at chest level to minimize swelling. Pedal pulse +3 bilateral:

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

Sodium 140 mEq/L - 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. wrong -potassium level of 2.9 mEq/L is below the expected reference range of 4.1 to 5.3 mEq/L and indicates hypokalemia. -urine specific gravity of 1.035 is above the expected reference range of 1.005 to 1.030 and indicates concentrated urine. -BUN level of 25 mg/dL is above the expected reference range of 5 to 18 mg/dL and indicates the kidneys are not excreting BUN

Nurse is planning educational program to teach parents about protecting children from sunburns. Which instructions should the nurse plan to include? a. "Allow your child to play outside during the hours between 10:00 a.m. and 2:00 p.m." b. "Choose a waterproof sunscreen with a minimum SPF of 15." c. "Dress your child in loose weave polyester fabric prior to sun exposure." d. "Reapply sunscreen every 4 hours."

"Choose a waterproof sunscreen with a minimum SPF of 15." -The nurse should instruct parents to apply a waterproof sunscreen with a minimum SPF of 15 for children. The parents should apply the sunscreen prior to sun exposure to reduce the risk of sunburn. Wrong - The nurse should instruct parents to avoid allowing their children to play outside during the hours between 1000 and 1400 because the child is at greatest risk for developing a sunburn during this time. - The nurse should instruct parents to dress their children in tight weave cotton fabric prior to sun exposure to protect the skin from the sun. - The nurse should instruct parents to reapply sunscreen every 2 to 3 hr.

Nurse gives discharge teaching to parent of 18 month old toddler with dehydration due to acute diarrhea. Which statements by parents indicate understanding of teaching?"I will offer my child small amounts of fruit juice frequently.""I will avoid giving my child solid foods until the diarrhea has stopped.""I will monitor my child's number of wet diapers.""I will give my child polyethylene glycol daily for 7 days."

"I will offer my child small amounts of fruit juice frequently.":- Children recovering from dehydration should not be encouraged to drink frequent, small amounts of fruit juice because it is high in carbohydrates, low in electrolytes, and has a high osmolality value."I will avoid giving my child solid foods until the diarrhea has stopped.":- The nurse should teach the parent to encourage solid foods as soon as the toddler is rehydrated to provide adequate nutrient intake.ANS: "I will monitor my child's number of wet diapers.":- The nurse should teach the parent to closely monitor the child's number of wet diapers. Monitoring the number of wet diapers per day is an effective way for the parent to monitor adequate output and hydration status."I will give my child polyethylene glycol daily for 7 days.":- Polyethylene glycol is an osmotic agent that will pull fluid into the bowel, increasing the frequency of stools, which will increase the level of dehydration.

School nurse provides in service for faculty about improving education for students with ADHD. Which statements by faculty member indicates understanding of teaching? a. "I will plan to increase the amount of homework I assign to students who have ADHD." b. "I will give students who have ADHD the same amount of time as other students to complete tests." c. "I will allow students who have ADHD one rest break throughout the day." d. "I will teach challenging academic subjects to students who have

"I will teach challenging academic subjects to students who have ADHD in the morning" - Faculty should plan to teach challenging academic subjects in the morning when students who have ADHD are most able to focus and their medication is most likely to be effective. Wrong "I will plan to increase the amount of homework I assign to students who have ADHD.":- Faculty should decrease the amount of school work and homework given to a child who has ADHD to maintain their attention. "I will give students who have ADHD the same amount of time as other students to complete tests.":- Students who have ADHD should be given additional time to take tests due to decreased attention. "I will allow students who have ADHD one rest break throughout the day.":- Faculty should allow frequent breaks throughout the day for students who have ADHD to modify their learning environment.

Nurse teaches guardian of 6 month old infant about teething. Which statements should the nurse make? a. "Your baby might pull at their ears when they are teething." b. "Rub your baby's gums with an aspirin to decrease discomfort." c. "Place a beaded teething necklace around your baby's neck." d. "Your baby's upper middle teeth will erupt first."

"Your baby might pull at their ears when they are teething.":- The nurse should inform the guardian that teething can result in discomfort for the infant. Therefore, the guardian should look for indications such as pulling on the ears, difficulty sleeping, increased drooling, or increased fussiness. wrong - The guardian should avoid using aspirin or teething powders due to the risk of aspiration, infection, or irritation of the gum tissues. The nurse should recommend cold teething rings or gently rubbing the infant's gums with a cold cloth to minimize discomfort. - Necklaces can result in suffocation and choking. Therefore, the nurse should instruct the guardian to avoid placing these on the infant. - The nurse should inform the guardian that the eruption of an infant's teeth begins with the lower central incisors.

Nurse gives discharge teaching to parent of school age child with moderate persistent asthma. Which instructions the nurse include? -"You should give your child their salmeterol inhaler every 4 hours when they are having an acute episode of wheezing." -"You should monitor your child's weight weekly while they are receiving inhaled corticosteroid therapy." -"Pulmonary function tests will be performed every 12 to 24 months to evaluate how your child is responding to therapy." -"When using the peak

"Pulmonary function tests will be performed every 12 to 24 months to evaluate how your child is responding to therapy." - The nurse should inform the parent that their child will need pulmonary function tests every 12 to 24 months to evaluate the presence of lung disease and how the child is responding to the current treatment regimen. As children grow, sometimes their manifestations can improve or decline, and treatment needs to change accordingly. Wrong - long-acting beta2 agonists are to be used in conjunction with a low- or medium-dosage inhaled corticosteroid, never used alone. - use of inhaled corticosteroids has not been shown to have any negative effects on growth. The provider might monitor the child's growth for systemic absorption. However, it is not necessary for the parent to weigh the child weekly. -measure the child's airflow using a peak expiratory flow meter. This should be done twice daily, taking three measurements each time and waiting 30 seconds between

Nurse teaches parents of preschooler with heart failure and new prescription for digoxin 2x daily. Which instructions should the nurse include in teaching?"Use a kitchen teaspoon to measure the medication.""Brush the child's teeth after giving the medication.""Double the next dose if the child misses a dose.""Repeat the dose if the child vomits."

"Use a kitchen teaspoon to measure the medication.":- The nurse should instruct the parents to use the calibrated device that comes with the medication when measuring the medication to avoid accidental overdose.ANS: "Brush the child's teeth after giving the medication.":- The nurse should instruct the parents to brush the child's teeth after administering digoxin to prevent tooth decay caused by the medication, which comes as a sweetened liquid to enhance the taste."Double the next dose if the child misses a dose.":- The parent should administer digoxin at regular intervals, usually twice daily, or every 12 hr. The nurse should instruct the parents not to double the medication amount if they miss a dose because this can result in digoxin toxicity."Repeat the dose if the child vomits.":- N/V, and decreased appetite are common manifestations of digoxin toxicity in children. The nurse should instruct the parents not to administer a second dose if the child vomits and to notify the provide

Nurse provides dietary teaching to guardian of school age child with cystic fibrosis. Which statements should nurse make? a. "You should offer your child high-protein meals and snacks throughout the day." b. "You should decrease your child's dietary fat intake to less than 10% of their caloric intake." c. "You should restrict your child's calorie intake to 1,200 per day." d. "You should give your child a multivitamin once weekly."

"You should offer your child high-protein meals and snacks throughout the day." The nurse should instruct the guardian to provide a diet that is well-balanced and high in protein and calories. Children who have cystic fibrosis require a higher percentage of the recommended dietary allowances of all nutrients to meet their energy requirements. Children who have good nutritional intake have improved lung function and decreased risk of infection."You should decrease your child's dietary fat intake to less than 10% of their caloric intake.":- Children who have cystic fibrosis need a diet that is unrestricted in fat. They also require 35% to 40% of their calories to come from fats due to decreased absorption from the intestines."You should restrict your child's calorie intake to 1,200 per day.":- Children who have cystic fibrosis require a high-calorie diet and should consume at least 2,000 calories per day."You should give your child a multivitamin once weekly.":- Children who have

A nurse is caring for a toddler. 13-month-old. Parent states toddler having trouble passing stool. Toddler awake and alert. Hypoactive bowel sounds. Provider recommended over-the-counter stool softener and encouraged hydration and increasing fruits and vegetables in diet. Week Later Toddler appears lethargic. Parent reports toddler uninterested in eating. Having ribbon-like, foul-smelling stools since last visit. Hypoactive bowel sounds. Abdomen distended, palpable fecal mass

0900, Today: Toddler presents to office today with parent. Toddler appears lethargic. Parent reports the toddler is uninterested in eating. Parent states the child is having ribbon-like, foul-smelling stools in diaper since last visit. S1 and S2 auscultated. Respirations are symmetric and unlabored, breath sounds clear. Hypoactive bowel sounds. Abdomen distended and palpable fecal mass noted on palpation. Temperature 37.3° C (99.2° F) axillary Heart rate 138/min Respiratory rate 26/min Blood pressure 110/70 mm Hg Oxygen saturation 98% on room air. Findings indicate the toddler's constipation has worsened and the toddler needs further evaluation for suspected Hirschsprung's disease.

Nurse provides discharge teaching to parents of 6 month old infant postop following hypospadias repair with stent placement. Which instructions should the nurse include in teaching?"You may bathe your infant in an infant bathtub when you go home.""Apply hydrocortisone cream to your infant's penis daily.""You should clamp your infant's stent twice daily.""Allow the stent to drain directly into your infant's diaper."

ANS: "Allow the stent to drain directly into your infant's diaper.":- The nurse should instruct the parents to ensure that the stent drains directly into the infant's diaper to prevent kinking or twisting that can interfere with urine flow. "You may bathe your infant in an infant bathtub when you go home.":- Submerging the stent in water can cause infection at the operative site. The parents should avoid placing the infant in an infant bathtub until after the provider removes the stent."Apply hydrocortisone cream to your infant's penis daily.":- Following surgical repair of a hypospadias, the infant is at increased risk for infection at the operative site. The nurse should instruct the parents to administer a prophylactic antibiotic as prescribed to help prevent infection."You should clamp your infant's stent twice daily.":- The stent in place following hypospadias repair allows urine to drain from the body. The nurse should instruct the parents to avoid blocking the stent to prevent

Nurse teaching school age child and parent about postop care following cardiac catheterization. Which instructions should the nurse include?"Stay home from school for 1 week following the procedure.""Follow a diet that is low in fiber for 1 week.""Wait 3 days before taking a tub bath.""Apply a pressure dressing to the site for 3 days."`

ANS: "Wait 3 days before taking a tub bath.":- The child should keep the site clean and dry for at least 3 days to reduce the risk of infection. Tub baths should be avoided for 3 days to avoid immersion of the incision in water.

Nurse creating POC (plan of care) for preschooler with Wilms' tumor and scheduled for surgery. Which interventions should the nurse include?Avoid palpating the abdomen when bathing the child before surgery.Refrain from auscultating the child's bowel sounds during the postoperative assessment.Encourage the child to play with other children on the unit prior to surgery.Explain to the child that their pain will be managed after the surgery.

ANS: Avoid palpating the abdomen when bathing the child before surgery:- The nurse should avoid palpating the abdomen when bathing the child before surgery because movement of the tumor can cause cancer cells to disseminate to other sites, adjacent and distant to the tumor site.Refrain from auscultating the child's bowel sounds during the postoperative assessment:- Auscultation of the child's bowel sounds to monitor for an obstruction is an important part of the postoperative assessment. Therefore, the nurse should auscultate bowel sounds following the surgery.Encourage the child to play with other children on the unit prior to surgery:- The child's risk for injury increases with physical activity. Therefore, the nurse should not encourage the child to play with other children on the unit.Explain to the child that their pain will be managed after the surgery:- Telling the child about pain prior to surgery will likely increase their fear and anxiety level. Therefore, the nurse should no

Nurse caring for school age child with primary nephrotic syndrome and taking prednisone. Following 1 week of txt, which manifestations indicates to nurse that med is effective?Decreased edemaIncreased abdominal girthDecreased appetiteIncreased protein in the urine

ANS: Decreased edema:- A child who has nephrotic syndrome can experience edema due to the increased glomerular permeability, which increases protein loss. Prednisone decreases glomerular permeability, which causes fluid to shift from the extracellular spaces, resulting in decreased edema.Increased abdominal girth:- The nurse should expect decreased abdominal girth with prednisone therapy.Decreased appetite:- Increased, rather than decreased, appetite is an expected manifestation of corticosteroid therapy.Increased protein in the urine:- The nurse should expect decreased protein in the urine with prednisone therapy.

Nurse discussing organ donation with parents of school age child who has sustained brain death due to bicycle crash. Which actions should the nurse take first?Inform the parents that written consent is required prior to organ donation.Provide written information to the parents about organ donation.Ask the provider to explain misconceptions of organ donation to the parents.Explore the parents' feelings and wishes regarding organ donation.

ANS: Explore the parents' feelings and wishes regarding organ donation:- The first action the nurse should take when using the nursing process is assessment. The nurse should first explore the parents' feelings and wishes regarding organ donation to assist in determining if organ donation is the right choice for the family.

Nurse assesses pain level of 3 y/o toddler. Which pain assessments should the nurse use?FACESNumericCRIESVisual analog

ANS: FACES:- The nurse should use the FACES pain rating scale for pediatric clients who are 3 years old and older. This scale allows the toddler to point to the face that depicts their current level of pain. The nurse can then determine the need for pain management. CRIES:- The nurse should use the CRIES pain assessment scale when assessing the need for pain management in infants who are less than 40 weeks of age. Visual analog:- The nurse should use the visual analog scale to assess pain for a child who is greater than 8 years of age. The visual analog scale allows the child to mark their pain on a centimeter ruler. Numeric:- The nurse should use the numeric pain rating scale when assessing the need for pain management in pediatric clients who are 8 years old and older. The nurse should identify that a 3-year-old toddler does not yet possess a concept of numbers and numerical value to effectively use this pain rating scale.

Nurse in ED cares for school age child with epiglottis. Which actions should the nurse take?Obtain a throat culture from the child.Monitor the child's oxygen saturation.Put a warm mist humidifier in the child's room.Place the child in the supine position.

ANS: Monitor the child's oxygen saturation:- The nurse should monitor the child's oxygen saturation level because the child is experiencing acute respiratory distress and it is necessary to determine if the child is responding to treatment. Obtain a throat culture from the child:- Obtaining a throat culture places the child at risk for complete airway obstruction. The nurse should wait until an airway is established for the child before performing any diagnostic testing.Put a warm mist humidifier in the child's room:- The nurse should administer humidified oxygen by face mask or blow-by, rather than place a warm mist humidifier in the child's room.Place the child in the supine position:- Placing the child in the supine position increases the child's risk for complete airway obstruction. The nurse should allow the child to be in whatever position they feel provides the most help with breathing. This is usually an upright position, and sometimes it is helpful for the child to lean forwa

Nurse is planning educational program for school age children and parents about bicycle safety. Which info should the nurse plan to include?The child should be able to stand on the balls of their feet when sitting on the bike.The child should ride their bike 2 feet to the side of other bike riders.The child should wear dark-colored clothing with a fluorescent stripe when riding at night.The child should ride the bike facing traffic when it is necessary to ride in the street.

ANS: The child should be able to stand on the balls of their feet when sitting on the bike:- To decrease the risk for injury, parents should ensure that the bike is the correct size for the child. When seated on the bike, the child should be able to stand with the ball of each foot touching the ground and should be able to stand with each foot flat on the ground when straddling the bike's center bar.The child should ride their bike 2 feet to the side of other bike riders:- To decrease the risk for injury, children should ride their bikes single file rather than side by side.The child should wear dark-colored clothing with a fluorescent stripe when riding at night:- To decrease the risk for injury when riding a bike at night, children should wear light-colored clothing that has fluorescent material attached. This measure, along with fluorescent material on the bike itself, makes bike riders more visible to motor vehicle drivers and other bike riders.The child should ride the bike facing

Nurse is admitting infant with intussusception. Which findings should the nurse expect? (SATA)SteatorrheaVomitingLethargyConstipationWeight gain

ANS: Vomiting is correct. The nurse should expect an infant who has intussusception to exhibit vomiting due to the obstruction that occurs when a segment of the bowel telescopes within another segment of the bowel.ANS: Lethargy is correct:- The nurse should expect an infant who has intussusception to exhibit lethargy due to episodes of severe pain during which the infant cries inconsolably, leading to exhaustion and decreased nutritional intake.Steatorrhea is incorrect:- The nurse should expect an infant who has intussusception to have bloody stools that are currant jelly-like in appearance. Steatorrhea is bulky, fatty stools, and is a manifestation of cystic fibrosis.Constipation is incorrect:- The nurse should expect an infant who has intussusception to have mucus-filled and red jelly-like diarrhea due to the leaking of blood and mucus into the intestinal lumen.Weight gain is incorrect:- The nurse should expect an infant who has intussusception to have weight loss due to anorexia and

Nurse caring for school age child with DM was admitted with Dx of diabetic ketoacidosis. When performing resp assessment, which findings should the nurse expect? a. Deep respirations of 32/min b. Shallow respirations of 10/min c. Paradoxic respirations of 26/min d. Periods of apnea lasting for 20 second

Deep respirations of 32/min:- The nurse should expect Kussmaul respirations in a child who has diabetic ketoacidosis. These deep and rapid respirations are the body's attempt to eliminate excess carbon dioxide and achieve a state of homeostasis. wrong -Shallow respirations of 10/min:- The nurse should expect shallow respirations in a child who has respiratory depression related to opioid administration. -Paradoxic respirations of 26/min:- The nurse should expect paradoxic respirations in a child who has flail chest. -Periods of apnea lasting for 20 seconds:- The nurse should expect periods of apnea lasting 20 seconds or more in a child who has sleep apnea.

Nurse creates POC for child with varicella. Which interventions should the nurse include? -Maintain the child's room temperature at 80° F. -Prepare the child for a lumbar puncture. -Administer aspirin to the child for a temperature greater than 38.3° C (101° F). -Initiate airborne precautions for the child.

Initiate airborne precautions for child:- The nurse should initiate airborne precautions for a child who has varicella because it is spread through droplets in the air. The incubation period for varicella is 2 to 3 weeks, and the child is contagious even before lesions appear.

Normal pediatric vital signs chart Age, Normal BP range (mm Hg), Normal HR (BPM) 1 to 3 years 90-105/55-70 (80-125 BPM) 3 to 6 years 95-110/60-75 (70-115 BPM) 6 to 12 years 100-120/60-75 (60-100 BPM) 12 to 18 years 100-120/70-80 (60-100 BPM)

Infants aged 0-2 months: >50 Infant 2 months to 1 year: 50 breaths per minute. Preschool Child 1 to 5 years: 40 breaths per minute. School-age Child: 20-30 breaths per minute. Adults: 20 breaths per minute.

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.

Initiate seizure precautions for the child.- 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. Wrong -AKI can develop a fever due to an infection. Because AKI is a contraindication for receiving medications that are nephrotoxic, such as NSAIDs, the nurse should use compensatory measures, such as turning on a fan in the room. -AKI is often hypertensive due to fluid volume excess and the activation of the renin-angiotensin system. To prevent complications, such as hypertensive encephalopathy, the nurse should assess the child's blood pressure every 4 to 6 hr. -AKI, decreased urine output and fluid retention. Result in water intoxication. Accurate evaluation of fluid balance, the nurse should plan to weigh the child daily, at the same time, in the same clothing, and using the same scale.

Nurse cares for infant receiving IV fluids for tx of Tetralogy of Fallot and begins to have hypercyanotic spell. Which actions should the nurse take? -Place the infant in a knee-chest position. -Administer a dose of meperidine IV. -Discontinue administration of IV fluids. -Apply oxygen at 2 L/min via nasal cannula.

Place the infant in a knee-chest position:- The nurse should place the infant in a knee-chest position during a hypercyanotic spell to decrease the return of desaturated venous blood from the legs and to direct more blood into the pulmonary artery by increasing systemic vascular resistance. Wrong -Administer a dose of meperidine IV:- administer morphine IV to the infant, instead of meperidine, to decrease infundibular spasms that cause a decrease in pulmonary blood flow and right-to-left shunting. -Discontinue administration of IV fluids:- continue the administration of IV fluids during a hypercyanotic spell to decrease the viscosity of the infant's blood, which decreases the risk of a cerebrovascular accident. -Apply oxygen at 2 L/min via nasal cannula:- apply oxygen 100% with face mask to assist with dilation of the pulmonary artery and improve oxygen supply to the brain.

Community health nurse assesses 18 month old toddler in community day care. Which findings should the nurse ID as potential indication of physical neglect? -Resists having an axillary temperature taken -Exhibits withdrawal behaviors when their parent leaves -Has multiple bruises on their knees -Poor personal hygiene

Poor personal hygiene A toddler who has poor personal hygiene can be a potential indication of physical neglect. Because toddlers are still dependent on their parents or guardians for help with hygiene needs, poor personal hygiene can indicate a lack of supervision. Wrong Resists having an axillary temperature taken:- A toddler has begun to develop a sense of body image and boundaries and can be resistant to intrusive assessments such as assessing the mouth or ears, or taking an axillary temperature. Exhibits withdrawal behaviors when their parent leaves:- Separation anxiety is an expected finding for a toddler. Toddlers can become fearful and exhibit regressive behaviors when left alone with strangers and separated from their parents. Has multiple bruises on their knees:- An 18-month-old toddler has typically accomplished the gross motor skills of standing and walking, and has likely started trying to run, which can result in them falling and bruising their knees.

Nurse caring for preschooler has congestive heart failure. Nurse observes wide QRS complexes and peaked T waves on cardiac monitor. Which prescriptions should the nurse clarify with HCP? Furosemide Captopril Regular Insulin Potassium Chloride

Potassium Chloride Identify that a child who has congestive heart failure can develop electrolyte imbalances, such as hyperkalemia or hypokalemia. The nurse should identify that the child is exhibiting manifestations of hyperkalemia and contact the provider about the administration of potassium chloride, which can increase the severity of hyperkalemia. A child who has congestive heart failure might need a diuretic to prevent fluid overload. Furosemide loop diuretic that excretes potassium. Captopril: congestive heart failure will require medications that cause vasodilation, such as ACE inhibitors, to reduce cardiac afterload. A child CHF can develop electrolyte imbalances. nurse should identify that the child is exhibiting manifestations hyperkalemia and insulin administered to facilitate movement of potassium into cells

Nurse assesses 6 month old during well-child visit. Which findings should the nurse report to HCP?Presence of a central incisor toothPresence of strabismusPresence of an open anterior fontanelPresence of external cerumen

Presence of a central incisor tooth:- The nurse should recognize that the presence of a central incisor tooth is an expected finding for a 6-month-old infant and is not necessary to report to the provider.ANS: Presence of strabismus:- Strabismus, or crossing of the eyes, typically disappears at 3 to 4 months of age. If not corrected early, this can lead to blindness. Therefore, the nurse should report this finding to the provider.Presence of an open anterior fontanel:- The nurse should recognize that the presence of an open anterior fontanel is an expected finding for a 6-month-old infant and is not necessary to report to the provider. The anterior fontanel generally closes around 12 months of age.Presence of external cerumen:- The nurse should recognize that the presence of cerumen, which is a soft, yellow-brown waxy substance found in the ear, is an expected finding for a 6-month-old infant and is not necessary to report to the provider.

Nurse assesses adolescent who received sodium polystyrene sulfonate enema. Which findings indicates effectiveness of med?Reports an absence of nausea and vomitingReports experiencing an onset of loose stools within 15 min of administrationSerum potassium level 4.1 mEq/LBlood pressure 86/52 mm Hg

Reports an absence of nausea and vomiting:- Absence of nausea and vomiting indicates effectiveness of an antiemetic medication. Sodium polystyrene sulfonate is an antidote, which exchanges sodium ions in the intestine. Reports experiencing an onset of loose stools within 15 min of administration:- The nurse should monitor the adolescent for diarrhea because it is an adverse effect of sodium polystyrene sulfonate.ANS: Serum potassium level 4.1 mEq/L:- The nurse should monitor the adolescent's serum potassium level following the administration of sodium polystyrene sulfonate. This medication is used to treat hyperkalemia by exchanging sodium ions for potassium ions in the intestine. Therefore, a potassium level within the expected reference range of 3.4 to 4.7 mEq/L indicates the effectiveness of the medication.Blood pressure 86/52 mm Hg:- below the expected reference range of 90 to 110 mm Hg systolic and 60 to 80 mm Hg diastolic for an adolescent and does not indicate effectiveness of t

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

Speech therapist 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. Wrong -occupational therapist for a child who has physical disabilities and requires assistance with ADLs. -physical therapist for a child who requires assistance with mobility and increasing physical strength.

A nurse on a pediatric unit is admitting a preschooler. Complete the following sentence by using the list of options. The nurse should identify that the child is at risk for developing _______ as evidence by ______. child has been tired lately and has been experiencing a sore throat and fever. Child is tolerating sips of liquids but is refusing solid foods. voiding dark yellow urine. 0730 Mucous membranes are dry and sticky. Skin turgor without tenting. Tonsils enlarged and erythematous.

Splenomegaly is correct. The child's positive mononucleosis rapid test result indicates the presence of infectious mononucleosis, a condition caused by the Epstein-Barr virus. Therefore, the nurse should identify that the child is at risk for developing splenomegaly, a common complication of infectious mononucleosis. Positive mononucleosis rapid test is correct. The child's positive mononucleosis rapid test result indicates the presence of infectious mononucleosis, a condition caused by the Epstein-Barr virus. Therefore, the nurse should identify that the child is at risk for developing splenomegaly, a common complication of infectious mononucleosis.

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

Substernal retractions - 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. wrong -The nurse should report an excoriated scrotal area to the provider. However, Priority -The nurse should report the presence of multiple capillary hemangiomas. Another priority -The nurse should report a depressed posterior fontanel. Another Priority

Nurse admitting a 4 month old infant with heart failure who is prescribed Digoxin 0.5 mcg PO Q12H Furosemide 20 mg PO Q12H. Which findings is the nurse's priority? a. Exhibits: Temperature 37.5° C (99.5° F), Heart rate 70/min, Respiratory rate 30/min b. Birth weight 3.2 kg (7 lb) Current weight 5.9 (13 lb) c. 3 episodes of vomiting 6 wet diapers in 24 hr d. Consumed 3 oz concentrated formula every 3 hr

c. Episodes of vomiting:- When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is three episodes of vomiting. This can indicate digoxin toxicity, which requires immediate intervention. Therefore, this is the nurse's priority finding. Wrong answers: d. Formula consumption - A 4-month-old infant who has heart failure requires 3 to 4 oz of formula every 3 hr to adequately address caloric needs. (A feeding schedule of every 2 hr does not allow sufficient rest time between feedings, and a feeding schedule of every 4 hr requires consumption of a higher volume, which is often not tolerated by the infant.) -An intake of 3 to 4 oz of formula every 3 hr indicates that the infant is tolerating the current feeding schedule. Therefore, there is another finding that is the nurse's priority. The infant who has heart failure is at risk for inadequate nutrition; therefore, the nurse should closely monitor the infant's intake. b. Weight - A

Nurse assesses 8 y/o child with early indications of shock. After establishing airway and stabilizing child's resp, which actions should the nurse take next? a. Insert an indwelling urinary catheter. b. Measure weight and height. c. Initiate IV access. d. Maintain ECG monitoring.

c. Initiate IV access - After establishing an airway and stabilizing the child's respirations, the next action the nurse should take when using the ABC approach to client care is to establish IV access to maintain the child's circulatory volume. Wrong Answers: a. Insert an indwelling urinary catheter - The nurse should insert an indwelling urinary catheter for a child who has early indications of shock. Strict intake and output monitoring is needed because UO decreases during shock due to reduced blood flow to the kidneys as the body attempts to conserve body fluids. However, there is another action that the nurse should take first. b. Measure weight and height - The nurse should measure weight and height of a child who has early indications of shock to calculate weight-based medication dosages. However, there is another action that the nurse should take first. c. Maintain ECG monitoring - The nurse should maintain ECG monitoring for a child who has early indications of shock to con

Nurse in ED assesses 3 month old infant with rotavirus and experiences acute vomiting and diarrhea. Which manifestations should nurse ID as indication that infant has moderate to severe dehydration? a. Heart rate 124/min b. Increased tear production c. Sunken anterior fontanel d. Cap refill 2 secs

c. Sunken anterior fontanel - The nurse should recognize that a sunken anterior fontanel is an indication of moderate to severe dehydration due to the acute loss of fluid. Wrong answers: a. Heart rate 124/min - within the expected reference range of 106 to 186/min for a 3- to 5-month-old infant. The nurse should expect the infant who has moderate to severe dehydration to have tachycardia. b. Increased tear production - An infant who has moderate to severe dehydration is more likely to have absence of tears rather than increased tear production. d. Capillary refill 2 sec - within the expected reference range of 2 seconds or less for a 3-month-old infant. An infant who has moderate to severe dehydration is more likely to have delayed capillary refill of greater than 2 seconds.