PrepU5

ensuring a patent airway

A 6-year-old boy has been admitted to the hospital with burns. The nurse notes carbonaceous sputum. What action would be the priority? estimating burn extent determining the burn depth ensuring a patent airway eliciting a description of the burn

Infection Explanation: Factors that may precipitate a sickle cell crisis include: fever, infection, dehydration, hot or humid environment, cold air or water temperature, high altitude, or excessive physical activity. Respiratory distress and pallor are general signs and symptoms of a sickle cell crisis.

A nurse is teaching the parents of a child with sickle cell disease about factors that predispose the child to a sickle cell crisis. The nurse determines that the teaching was successful when the parents identify what as a factor? Pallor Respiratory distress Fluid overload Infection

Monitoring for allergic reactions or anaphylaxis Explanation: The nurse would monitor for infusion-related reactions and anaphylaxis if monoclonal antibodies were administered and would have epinephrine, antihistamines, and steroids available at the bedside for treatment if a reaction occurred. Assessing the level of hydration due to vomiting would be necessary if tumor necrosis factor was administered. The flu-like symptoms produced by interferons require hydration maintenance also. Monitoring for complaints of bone pain is appropriate when administering colony-stimulating factors such as filgrastim or sargramostim. Assessing for signs of capillary leak syndrome within 2 to 12 hours of the start of treatment is necessary when interleukins are used.

The nurse is caring for a 6-year-old boy with non-Hodgkin lymphoma who is being treated with monoclonal antibodies. What recommendation would the nurse include in the child's plan of care? Assessing the child's hydration status secondary to vomiting. Assessing for signs of capillary leak syndrome. Monitoring for complaints of bone pain. Monitoring for allergic reactions or anaphylaxis.

Brush his or her teeth Explanation: To prevent staining of the teeth, the child should brush the teeth after administration of iron preparations such as ferrous sulfate. There is no need to remain upright, drink milk or to refrain from eating or drinking for one hour.

The child is prescribed liquid ferrous sulfate. The nurse should encourage the child to take which action immediately after each dose to best eliminate possible side effects? Not eat or drink for one hour Remain in an upright position for at least 15 minutes Drink a glass of milk Brush his or her teeth

"Milestones are often delayed for children with Down Syndrome."

The clinic nurse talks with the parent of a child with Down syndrome. The parent states, "I thought my 1-year-old would be walking by now. I am concerned." What response by the nurse is best? "Milestones are often delayed for children with Down Syndrome." "How old was your child when he or she first begin to smile?" "We should ask a physical therapist to address your concern." "How many other children do you and your husband have?"

"I will set our water heater at 130°F (54°C)."

The nurse is teaching the mother of a toddler about burn prevention. Which response by the mother indicates a need for further teaching? "The handles of pots on the stove should face inward." "I will set our water heater at 130°F (54°C)." "We will leave fireworks displays to the professionals." "All sleepwear should be flame retardant."

Swimming Explanation: Swimming, a noncontact sport or activity, would be the safest for the nurse to recommend. Soccer and gymnastics may be appropriate; however, these are considered riskier. Rugby would not be recommended because the risks outweigh the benefits.

The parents of a child with a bleeding disorder ask the nurse about appropriate activities and sports that they should encourage the child to participate in. What activity would be the safest for the nurse to suggest? Gymnastics Swimming Rugby Soccer

lymph node biopsy

A 12-year-old child is suspected of having Hodgkin lymphoma. When preparing the child and family for diagnostic testing, which test would the nurse describe as being used to confirm the diagnosis? lymph node biopsy chest computed tomography liver function tests 24-hour urine test

His stools will appear black. Explanation: A side effect of ferrous sulfate therapy is to color stools black.

A 9-month-old infant with iron-deficiency anemia is given ferrous sulfate therapy. Which assessment would best help the nurse determine that the infant is actually taking it daily? The infant will be more irritable than at the last visit. The stools will appear black. The reticulocyte count will have decreased. The infant will develop diarrhea.

"This test will tell if your child has an infection or inflammation somewhere in their body."

A child has an order for an erythrocyte sedimentation rate (ESR). The child's mother asks what the purpose of the test is. What is the best response by the nurse? "This test will tell if your child has a fungus somewhere in their body." "This is a test to determine if your child has a skin infection." "This test will tell if your child has allergies." "This test will tell if your child has an infection or inflammation somewhere in their body."

induction

A child is scheduled for chemotherapy as treatment for leukemia. As the nurse is collaborating with another colleague, the discussion turns to the client's first phase of chemotherapy. This phase is known as: induction. sanctuary. maintenance. delayed intensive therapy.

Discontinue the transfusion.

A nurse is administering a blood transfusion to a child. About 35 minutes after beginning the transfusion, the child develops pruritus and urticaria. Some wheezing is noted. Which action would the nurse take first? Give an iron-chelating agent. Discontinue the transfusion. Obtain a blood culture. Ask the health care provide for a prescription for a diuretic.

1.0

A nurse is reviewing the laboratory test results of a 3-year-old child. Which absolute neutrophil count would the nurse identify as indicating neutropenia? 1.5 1.0 2.0 2.5

Cover with a clean nonadhesive bandage. Rinse the burned area in cool water.

A teen has experienced a minor burn from a hair styling appliance. What interventions will be of benefit? Select all that apply. Apply ice intermittently. Use aspirin for pain. Cover with a clean nonadhesive bandage. Apply a thin layer of butter on the burned area. Rinse the burned area in cool water.

pouring unused chemotherapy medicine into a sink drain

An experienced nurse is orienting a new nurse to the oncology unit. Which action by the new nurse would require intervention? providing information about nausea, mucositis, and susceptibility to infection pouring unused chemotherapy medicine into a sink drain washing hands well after administering chemotherapy wearing gloves when administering chemotherapy

Impetigo is highly contagious and can spread quickly.

The community nurse receives a call from a local day care center. One of the children in the center has been diagnosed with impetigo. Which information related to impetigo will the nurse provide to the day care center? Impetigo is highly contagious and can spread quickly. The facility staff should wear masks until all children and adults are healthy. Impetigo cannot be treated with medication and has to run its course. Impetigo usually develops because of sensitivity to pollens and molds.

tachycardia and respiratory distress

The nurse is caring for a 6-year-old girl with leukemia who is having an oncologic emergency. Which signs and symptoms would indicate hyperleukocytosis? tachycardia and respiratory distress wheezing and diminished breath sounds bradycardia and distinct S1 and S2 sounds respiratory distress and poor perfusion

Craving for ice cubes

The nurse is concerned that a school-aged child has iron-deficiency anemia. What did the nurse assess in this client? Craving for ice cubes Thumb-sucking Asking many questions Shyness

Bone marrow Explanation: A child with cancer often appears pale and thin, with symptoms of lethargy and generalized malaise. The presence of pallor, ecchymoses, and petechiae may indicate that the cancer has invaded the bone marrow and is interrupting the normal production of red blood cells and platelets, as in leukemia.

The nurse is examining a child who was diagnosed with acute lymphoblastic leukemia (ALL) 6 months ago. The child exhibits pallor, ecchymoses, and petechiae. The nurse interprets these findings as indicating that the cancer has invaded which part of the body? bloodstream lymph nodes liver bone marrow

Calling the doctor if the child gets a sore throat

The nurse is preparing a discharge teaching plan for the parents of an 8-year-old girl with leukemia. Which instruction would be the priority? Using acetaminophen if the child needs an analgesic Keeping a written copy of the treatment plan Calling the doctor if the child gets a sore throat Writing down phone numbers and appointments

Continue to assess the infant to look for other abnormalities.

Upon assessment, the nurse notices that the infant's ears are low-set. What is the priority action by the nurse? Inform the parents that low-set ears are a sign of Down syndrome. Continue to assess the infant to look for other abnormalities. Place the infant on a cardiac monitor. Give a vitamin B12 injection to combat the metabolic disorder.

"Keep in mind that the signs of leukemia are often subtle and difficult to recognize." Explanation: Pointing out that the signs and symptoms of leukemia are often difficult to recognize indicates to the parents that they were not neglectful, while also providing information about the disease. The other responses minimize the parents' feelings or tell them how they should feel and are not therapeutic.

What is the best response by the nurse to the parents of a child with leukemia who express guilt because they did not take immediate action when their child seemed to develop one respiratory infection after another? "You need to focus on the present treatment now and not worry about the past." "Don't feel bad. Children get lots of colds." "Keep in mind that the signs of leukemia are often subtle and difficult to recognize." "Young children develop minor illness easily and often. Stop being hard on yourselves."

"I have to make sure that I do not become pregnant while taking this drug."

An adolescent is prescribed isotretinoin. Which statement indicates that the adolescent understands the necessary precautions associated with this drug? "I'm going to have to have a blood count done every couple of months." "This drug can affect my lungs so I need a chest radiograph done first." "The drug might cause staining of my clothing." "I have to make sure that I do not become pregnant while taking this drug."

Risk for impaired skin integrity related to oral ulcerations associated with chemotherapy

A child with acute lymphoblastic leukemia (ALL) is receiving methotrexate for therapy. Which nursing diagnosis would best apply during therapy? Excess fluid volume related to effect of methotrexate on aldosterone secretion Risk for impaired skin integrity related to oral ulcerations associated with chemotherapy Risk for self-directed violence related to effect of methotrexate on central nervous system Risk for impaired mobility related to depressant effects of methotrexate

Anorexia

A child with attention deficit hyperactivity disorder (ADHD) is prescribed methylphenidate hydrochloride. What should the nurse instruct the parents regarding an adverse effect of this medication? Garbled speech Sleepiness Anorexia Rapid increase in height

Keep him away from people with known infections

A nurse is giving instructions to the father of a boy who is receiving chemotherapy (including methotrexate) regarding how best to care for the boy during this period of treatment. What should the nurse mention to him? Be sure that the boy receives only live-virus vaccines Give him aspirin to help manage pain Give the boy folic acid supplements Keep him away from people with known infections

"Does your child interact with you when playing?"

A parent expresses concern that the child has an autism spectrum disorder. The nurse obtains a health history of the symptoms to understand the parent's concern. Which question would the nurse ask first? "Is your child happy when friends come to visit?" "Does your child interact with you when playing?" "Does your child respond to his or her name?" "Does your child only eat the same food?"

Initiate intravenous access. Explanation: In a situation where the child is experiencing a sickle cell crisis, a priority nursing action is to initiate intravenous access to begin rehydrating the child to halt the sickling process.

The nurse is caring for a child with sickle-cell anemia admitted to the pediatric unit. The child reports severe pain and fever. The nurse notes the following laboratory values: white blood cells 18,000/mm3, hemoglobin 6.6 mg/dl (66 g/L), and bilirubin 8 mg/dl (136.83 µmol/L). Which nursing action is priority? Administer pain medication. Initiate intravenous access. Begin an exchange transfusion. Assess the child's temperature.

Observation reveals a microcephalic head. Children with trisomy 13 have microcephalic heads with malformed ears and small eyes. Severe hypotonia, hypoplastic fingernails, and clenched fists with index and small fingers overlapping the middle fingers are typical symptoms of trisomy 18.

The nurse is performing a physical examination on a 1-week-old girl with trisomy 13. What would the nurse expect to assess? Inspection reveals hypoplastic fingernails. Observation discloses severe hypotonia. Inspection shows a clenched fist with overlapping fingers. Observation reveals a microcephalic head.

history of corrective surgery for anal atresia The nurse would likely find records of corrective surgery for anal atresia because it is a symptom of VATER association. The nurse may observe that the child has a hearing deficit, underdeveloped labia, and a coloboma, along with heart disease, retarded growth and development, and choanal atresia if the child had CHARGE syndrome.

The nurse is examining a 2-year-old girl with VATER association. Which sign or symptom should be noted? history of corrective surgery for anal atresia use of hearing aid underdeveloped labia cleft in the iris