VATI Care of children 2019
A nurse obtains a fingerstick glucose result of 45 mg/dL from a school age child who has diabetes mellitus. Which of the following actions should the nurse take?
Give the child 10-15g of a simple carbohydrate. -Identify that immediate attention is required to increase the child's glucose level to an acceptable range. Therefore, the nurse should provide 10-15g of a simple carbs, such as 3-6oz of OJ, following by a complex carb and protein in order to treat mild to moderate hypoglycemia.
A nurse is teaching the guardian of a school age child who has juvenile idiopathic arthritis about managing pain. Which of the following instructions should the nurse include?
Have an elevated toilet seat for use by the child. -Activities that involve bending or squatting can be difficult and painful for a child who has juvenile idiopathic arthritis. The use of an elevated toilet seat can promote independence with ADLs and increase the child's comfort.
A nurse is providing nutritional teaching to the patents of a child who has acute glomerulonephritis with pitting edema. Which of the following foods should the nurse recommend be eliminated from the child's diet?'
Hot dogs ➡ Results in edema, HTN, hematuria and proteinuria. Dietary changes requires limit foods high in sodium because of the edema and HTN. (Hot dogs, or other processed meats) glomerulonephritis - Glomerulonephritis is a type of kidney disease where these coils become inflamed. This makes it hard for the kidneys to filter the blood Diet changes to child's diet include protein and how much child may need, potassium may be limited, phosphorus limits (phosphorus makes bones weak), a low-sodium diet glomerulonephritis - Acute and chronic glomerulonephritis can develop from a systemic infection and involves the glomeruli of the kidney or the area responsible for filtering particles from the blood to make urine. Pitting edema - occurs when excess fluid builds up in the body, causing swelling; when pressure is applied to the swollen area, a "pit", or indentation, will remain.
A school nurse is providing dietary teaching for an 11-year-old child who has type 1 diabetes mellitus. The nurse should identify which of the following responses by the child indicates an understanding of the teaching? SATA
➡ I should eat extra food on busy days when I am more active. ➡ I should increase my intake of sugar free fluids when I am sick. ➡ I should eat a snack 30mins before my baseball game states. -Food intake should be adjusted to compensate for the release of insulin into the circulatory system and prevent episodes of hypoglycemia. The recommended increase of carbs is 10-15g per hr. of moderate play or activity. -Fluids flush out ketones to prevent dehydrations. Recommend sugar free liquids, such as water, broth, and tea to the child. Continue with usual intake of mealtimes and follow their recommended meal plan as much as possible. -If the game is prolonged they should have a snack every 45mins to an hour. If they cannot tolerate the extra food, the next intervention is to decrease the insulin dose before the game.
A nurse is preparing to administer erythromycin 50mg/kg/day in divided doses every 6hrs to an adolescent who is postoperative following surgical removal of a peritonsillar abscess and weights 40kg. Available is erythromycin oral solution 200mg/5mL. How many mL should the nurse administer with each dose?
12.5 mL
A nurse is teaching a group of new parents about expected language development. The nurse should include that a child should begin to speak 10 or more words about which of the following ages?
18 months -The toddler should also form simple word combinations. • Language increases to between 50 and 300 words by the age of 2 years. • 1 year: has a three to five word vocabulary; understands simple commands. • 2 to 3 years: using multiword sentences by combining two to three words; language increases to about 300 words; imitates animal sounds; refers to self by name; begins to use verbs in past tense.
A charge nurse on a pediatric unit is reviewing informed consent guidelines with newly licensed nurse. For which of the following clients should the nurse obtain informed consent from a guardian?
A 15-year-old client who requires an open reduction of a fracture. ➡ Sign consent prior to surgical procedures for a minor. • Informed consent is a legal process by which a client or the client's legally appointed designee has given written permission for a procedure or treatment. Consent is informed when a provider explains and the client understands: ➡ The reason the client needs the treatment or procedure. ➡ How the treatment or procedure will benefit the client. ➡ The risks involved if the client chooses to receive the treatment or procedure. ➡ Other options to treat the problem, including not treating the problem. • The nurse's role in the informed consent process is to witness the client's signature on the informed consent form and to ensure that the provider has obtained the informed consent responsibly.
A nurse is assessing an infant who has Tetralogy of Fallot. Which of the following clinical manifestations should the nurse expect? SATA
A heart murmur Cyanotic spells -Tetralogy of Fallot exhibit a systolic murmur that is moderate in intensity. -Experience anoxic spells when the infant's oxygen requirements exceed the oxygen available in the blood supply, such as when the infant is crying or following a feeding. Four defects that result in mixed blood flow: Pulmonary stenosis, ventricular septal defect, overriding aorta, right ventricular hypertrophy • Cyanosis at birth: progressive cyanosis over the first year of life • Systolic murmur • Episodes of acute cyanosis and hypoxia (blue or 'Tet" spells)
A nurse is documenting a male infants weight on a growth chart. The infant is 11months old and weights 11.3KG (24.9lbs). Identify the correct point on the graph where the nurse should plot the infants weight.
A is correct.
A nurse is assessing a 9-month-old infant who has gastroenteritis. Which of the following findings should the nurse identify as a manifestation of severe fluid volume deficit?
Absence of tears when crying. -Other manifestations of severe fluid volume deficit include: sunken eyeballs, parched mucous membranes, oliguria, sunken fontanels, and hyperpnea.
A nurse is planning a community education series for teachers of children who have attention-deficit hyperactivity disorder (ADHD). Which of the following classroom strategies should the nurse include in the teaching?
Accompany verbal instructions with visual references. - Use visual references along with verbal instructions for child who have ADHD. Using both verbal and written instruction provides clear communication of expectations for the children.
A nurse in the emergency department is caring for a preschool age child who has hemophilia A and sustained an abdominal trauma following a motor vehicle crash. Which of the following actions should the nurse take? SATA
Administer factor VIII. Assess for changes in LOC. -Bleeding disorder caused by a factor VIII deficiency; therefore, the nurse to administer factor VIII prophylactical to prevent or minimize bleeding. -Hemophilia A can cause cerebral bleeding; therefore, the nurse should assess the child for HA and decreased LOC.
A nurse is teaching a newly licensed nurse how to provide care for a child who has just been placed in skeletal traction. Which of the following information should the nurse include?
Administer prescribed opioid analgesics around the clock. -Common for children who have been place in skeletal traction to experience increased pain. Therefore, the nurse should administer prescribed opioids analgesics and muscle relaxants around the clock. • Skeletal traction uses a continuous pulling force that is applied directly to the skeletal structure and/or specific bone. It is used when more pulling force is needed than skin traction can withstand. A pin or rod is inserted through or into the bone. Force is applied through the use of weights attached by rope. The weights are never to be removed by the nurse.
A nurse is admitting a school age child who has rubeola measles. Which of the following precautions should the nurse plan to initiate?
Airborne precautions. -Transmitted by direct contact with small droplets from the infected person and that airborne precautions are used for prevention of transmission of microorganisms smaller than 5 microns. Therefore, the nurse should plan to initiate airborne precautions when admitting a child who has rubeola measles.
A nurse is creating a plan of care for a school age child who is postoperative following a tonsillectomy. Which of the following interventions should the nurse include?
Apply an ice collar to the child's neck. -To promote comfort and minimize swelling. The nurse also should administer prescribed analgesics to the child around the clock to minimize pain.
A nurse is reviewing the admission laboratory report of a school age child who has glomerulonephritis. Which of the following laboratory results should the nurse expect to find?
BUN 32 mg/dL -Above the expected reference range of 5-18 mg/dL for a child. A child who has glomerulonephritis will have an elevated BUN because of the impaired glomerular filtration rate, which results in retention of urea in the blood. BUN: checks Nitrogen in the blood
A nurse is planning care for a child who has cerebral palsy and is experiencing muscle spasms. Which of the following medications should the nurse expect to administer?
Baclofen -Centrally acting skeletal muscle relaxant that will decrease muscle spasm and sever spasticity. Think: Relax your BACk - Baclofen
A nurse is assessing a preschooler who was recently diagnosed with acute lymphoid leukemia. Which of the following findings should the nurse expect?
Bruising on the arms and legs. -Low platelet count is an expected findings for a preschooler who has acute lymphoid leukemia. A low platelet count causes petechiae, easy bleeding of the oral mucus membranes, and bruising of the arms and legs.
A nurse is providing teaching about preventing diaper dermatitis to a group of guardians. Which of the following instructions should the nurse include in the teaching?
Change diapers as soon as they become soiled with feces, including during the night. -Diaper dermatitis is caused by moist, soiled diapers, especially those soiled with feces.
A nurse is planning care for a school age child who is experiencing a vaso-occlusive crisis. Which of the following actions should the nurse take first?
Encourage the child to increase their fluid intake. -The first action the nurse should take is to promote hydration through the use of oral and IV fluids. Hydration is important because it prevents further sickling of the cells and delays the hypoxia-ischemia cycle.
A nurse is caring for an infant who has pyloric stenosis and a new prescription for 0.9% sodium chloride with 10mEq of potassium chloride. The infant is lethargic and has a potassium level of 3.5 mEq/L. Which of the following actions should the nurse take?
Check the infant's serum creatinine. - And BUN levels prior to and during the administration of IV potassium to ensure renal function is adequate and avoid the development of hyperkalemia should renal failure occur. The nurse should closely monitor I&O to ensure adequate urinary output prior to and during administration of IV potassium. Creatinine - test how well the kidneys filter
A nurse is assessing a toddler. Which of the following findings should the nurse identify as an indication of potential child maltreatment?
Circular burns on the soles of the toddlers feet. -Physical manifestations of burns are often found on the soles, back, buttocks, and hands. The nurse should document the location of the burns along with a description of the pattern and the presence of eschar or blistering. The nurse should also obtain diagrams and photographs using a measurement tool.
A nurse is reviewing the laboratory test results of a school age child. Which of the following findings should the nurse report to the provider?
Creatinine 1.6 mg/dL. -Outside the expected reference range of 0.3-0.6 mg/dL for school age child and should be reported. Creatinine: 0.6 - 1.2 (used to test how well the kidney's filter)
A nurse is assessing a child who has heart failure. Which of the following clinical manifestations should the nurse expect?
Distended neck veins. -Manifestations of increased blood volume, such as distended neck veins. This occurs because of the secretion of the hormone ADH, which holds onto sodium and water in response to decreased cardiac output and renal perfusion.
A nurse is admitting a child who has pertussis. Which of the following isolation precautions should the nurse initiate for the child?
Droplet -And other infections that is transmitted through respiratory droplets larger than 5 microns in size. (diphtheria, rubella, and scarlet fever require droplet precautions. Droplet precautions requires staff who provide care to wear a mask or respirator as PPE.
A nurse is providing discharge teaching to the guardians of a school age child following a tonsillectomy. Which of the following instructions should the nurse include?
Eat soft, bland foods as tolerated. -Cooked and mashed fruits, sherbet or ice-cream, soup, and mashed potatoes are examples of soft foods the nurse should recommend.
A nurse is providing discharge teaching to the parents of a school age child who is immobilized following spinal surgery. Which of the following nutritional recommendations should the nurse include?
Encourage small, frequent meals high in protein. -Immobilization causes a decrease in appetite. Therefore, small but frequent meals will be more readily tolerated. Adequate protein intake is needed for energy and tissue healing.
A nurse is providing discharge teaching to the parents of a school age child who has epilepsy and a new prescription for phenytoin extended release capsules. Which of the following instructions should the nurse include in the teaching?
Encourage the child to brush their teeth after each meal. ➡ Dental hygiene, this medications can cause gingival hyperplasia, and good oral hygiene reduces the risk of this occurring. • Epilepsy - brain disorder causing seizures • phenytoin (Dilantin) - control seizures (convulsions) • Gingival hyperplasia is an overgrowth of gum tissue around the teeth. There are a number of causes for this condition, but it's often a symptom of poor oral hygiene or a side effect of using certain medications
A nurse is planning care for a newly admitted child who has autism spectrum disorder. Which of the following interventions should the nurse include in the plan?
Establish a reward system for the child. -Respond to positive reinforcement. This helps to promote a therapeutic environment for the child.
A nurse is assessing a 2-year-old child following a surgical procedure. Which of the following pain tools should the nurse use?
Face, Legs, Activity, Cry Consolability (FLACC) scale. -The FLACC scale is used for infants and children from 2 months to 7 years.
A nurse is assessing an infant who has a congenital heart defect. Which of the following findings is the priority for the nurse to report to the provider?
Hyperpnea -Hyperpnea is an increased rate and depth of breathing due to severe hypoxemia.
A nurse is providing teaching about food choices to the parent of a school age child who has celiac disease. Which of the following statements by the parent indicates an understanding of the teaching?
I can offer popcorn as a snack food. -Unable to digest gluten found in grains, such as wheat, barley, rye, and oats. Corn is an acceptable substitute grain and is gluten-free. Therefore, popcorn is an appropriate food for the parent to offer the child as a snack. ➡ Celiac disease, sometimes called celiac sprue or gluten-sensitive enteropathy, is an immune reaction to eating gluten, a protein found in wheat, barley and rye. If you have celiac disease, eating gluten triggers an immune response in your small intestine.
A nurse is providing nutritional teaching to the parents of a 2-year-old child. Which of the following statements by the parent indicates an understanding of the teaching?
I should feed my child 1 cup of vegetables per day. -A variety of vegetables should be introduced to the toddler.
A nurse in a pediatric clinic is providing teaching to the parent of an infant who has gastroesophageal reflux (GER). The nurse should identify that which of the following statements by the parent indicates an understanding of the teaching?
I will add rice cereal to my baby's feedings. -Add rice cereal to formula or expressed breast milk to thicken the feeding. Thickened feeding can decrease the number of vomiting episodes the infant experiences. • Gastroesophageal reflux (GER) occurs when gastric contents reflux back up into the esophagus, making esophageal mucosa vulnerable to injury from gastric acid. • Gastrosophageal reflux disease (GERD) is tissue damage from GER. • GER is self-limiting and usually resolves by 1 year of age.
A nurse is admitting a child who has a vesicular rash of unknown etiology. Which of the following actions should the nurse take first?
Implement transmission precautions. -Greatest risk when admitting a child who has vesicular rash of unknown etiology is the spread of infection. Therefore, the first action the nurse should take is to implement transmission precautions. After the child has been diagnosed, the precautions can be modified accordingly. Vesicle is an important term used to describe the appearance of many rashes that typically consist of or begin with tiny-to-small fluid-filled blisters
A nurse is teaching the parent of a school age child who has cystic fibrosis about home care. Which of the following statements by the parent indicates an understanding of the teaching?
I will give my child stool softeners for constipation. -Can occur because of a failure to properly break down foods, a slowing of the intestinal motility, and the thickened enzymatic secretions die to the disease process itself. The parent should administer an osmotic solution, such as polyethylene glycol, stool softeners, or laxatives to treat constipation. ➡ Cystic fibrosis is a respiratory disorder that results from inheriting a mutated gene. It is characterized by mucus glands that secrete an increase in the quantity of thick, tenacious mucus, which leads to mechanical obstruction of organs (pancreas, lungs, liver, small intestine, and reproductive system); an increase in organic and enzymatic constituents in the saliva; an increase in the sodium and chloride content of sweat; and autonomic nervous system abnormalities.
A nurse is providing discharge teaching to the parent of a school age child who has juvenile idiopathic arthritis (JIA). The nurse should identify that which of the following responses by the parent indicates an understanding of the teaching?
I will have my child wear splints during the night. -To prevent joint deformities and reduce and minimize pain from inactivity.
A nurse is providing discharge teaching to the parent of a 5-year-old child who has leukemia and is receiving chemotherapy. Which of the following statements by the parent indicates an understanding of the teaching?
I will make sure to inspect my son's mouth every day for sores. -Increase risk for mucositis, therefore, the parent should inspect the mouth daily for lesions or ulcerations and report these to the provider. Open lesions can become infected in the child who is immunocompromised.
A nurse is providing a presentation for parents of a toddler about preventing childhood burns. Which of the following statements by a parent indicates and understanding of the teaching?
I will plug protective guards into my electrical outlets. - Plug protective guards into electrical outlets or place furniture in front of the outlets to protect the toddler from electrical shock or burns.
A nurse is teaching an adolescent how to use a peak expiratory flow meter (PEFM). The nurse should identify that which of the following statements by the child indicates an understanding of the teaching?
I will record the highest reading of the three attempts. -The child should forcefully exhale for 1sec as quickly as possible to measure the amount of air exhaled and repeat this process 3 times. The child should wait 30secs between attempts and record the highest of the the three readings.
A nurse is planning care for an infant who has respiratory syncytial virus (RSV) and a respiratory rate of 46/min. Which of the following interventions should the nurse include in the plan of care?
Initiate contact precautions. -The nurse should initiate contact, droplet, and standard precautions for RSV because exposure to contaminated secretions' can transmit the virus. RSV can live on objects for several hours and on hands for 30mins.
A nurse is caring for a child who has bacterial meningitis. Which of the following actions should the nurse take first?
Initiate droplet precautions. -To reduce the risk of transmission of the infection to others.
A nurse is assessing a child who has full-thickness burns of the legs. Which of the following manifestations should the nurse expect?
Injured skin is cream to black in color. -Variable colors, including cream to brown or black. The injury reaches through the epidermis to the dermis, and possibly to the muscles, tendons, and bone. Areas with a full thickness burn are less painful than partial thickness burned areas because of the nerve destruction involved.
A nurse is providing teaching to the guardian of a preschooler who has impetigo. Which of the following instructions should the nurse include?
Keep the child's towels separate from towels used by other family members. -Impetigo is a bacterial skin infection spread by contact.
A nurse is providing discharge teaching to a group of guardians of infants about home safety. Which of the following statements should the nurse make?
Keep your infant restrained when they are in a highchair. -Restrain infant while sitting in a highchair using the included straps with a closure. This will prevent the infant from falling out of the chair and decrease the risk of injury. Avoid leaving their infant in a highchair unattended because of the risk of slipping down in the chair and strangling on the safety straps.
A nurse is caring for a toddler who is experiencing hyperglycemia. Which of the following manifestations should the nurse expect?
Lethargic mood. -Will be irritable and have a labile mood. • Polyuria, Polydipsia, Polyphagia, Kusmaul Respirations, Recurrent Infections • Other manifestations: Acetone/fruity smelling breath, h/a, nausea, vomiting, abdominal pain, inability to concentrate, fatigue, weakness, vision changes, slow healing, decreased levels of consciousness, seizures leading to coma
A nurse is assessing a 4-year-old child who is 2 days postoperative following insertion of a ventriculoperitoneal shunt. Which of the following findings is the nurse's priority?
Lethargy -This can indicate a decrease level of consciousness or increased intracranial pressure, both of which requires immediate intervention. ➡ A ventriculoperitoneal (VP) shunt is a thin plastic tube that helps drain extra cerebrospinal fluid (CSF) from the brain.
A nurse is creating a plan of care for a school-age child who has moderate partial thickness burns on both lower extremities. Which of the following interventions should the nurse include in the plan?
Maintain aseptic technique during the child dressing changes. ➡ To prevent infection. Delayed wound healing can occur due to infection, which can also cause partial thickness wounds to develop into full thickness wounds.
A nurse is planning care for a toddler following a cardiac catheterization. Which of the following actions should the nurse take?
Maintain the child's affected leg in a straight position for at least 6hrs. -Maintain leg straight position for 6-6hrs following the procedure to allow for the artery to clot. Moving the leg can disrupt the integrity of the clot and cause bleeding.
A nurse is teaching the parents of an infant how to administer antibiotic eardrops. Which of the following instructions should the nurse include in the teaching?
Massage the anterior area of the ear following administration. -Just in front of the tragus, following administration to facilitate instillation of the medication into the ear canal.
A nurse is caring for an infant who has returned to the pediatric unit following surgical repair of a cleft lip. Which of the following actions should the nurse take?
Monitor temporal artery temperature. -Check temperature by scanning the temporal artery to monitor for manifestation of infection. Other manifestations of infection include redness, warmth, and drainage from the incision site.
A nurse in an emergency department is assessing a 5-year-old child who has a concussion. Which of the following manifestations should the nurse identify as an early indication of ICP?
Nausea ➡ Early findings of ICP (N + V normally projectile)
A nurse is caring for a 3-year-old child who has viral meningitis. Which of the following finding should the nurse expect?
Nuchal rigidity -Which is caused by meningeal irritation. The child also might have fever and photophobia. Nuchal rigidity - neck stiffness Meningitis - inflammation of the meninges, the membranes that protect the brain and spinal cord
A nurse is preparing to obtain a blood sample for an Hgb from a child who has hemophilia. Which of the following actions should the nurse plan to take?
Obtain the sample using venipuncture. -Because this method allows for less bleeding than a finger puncture.
A nurse in a well child clinic is assessing a school age child who has erythema on the face and maculopapular rash on the arms and legs. The parent reports that the child has had an intermittent fever for 1wk. Which of the following actions should the nurse take?
Offer the child analgesic for comfort. -Offer analgesics and antipyretic medications because erythema on the face and a maculopapular rash on the arms and legs indicates that the child has erythema infectiosum (fifth disease). Erythema infectiosum is a viral infection that cannot be treated with antibiotics. A maculopapular rash is a type of rash characterized by a flat, red area on the skin that is covered with small confluent bumps. It may only appear red in lighter-skinned people
A nurse is teaching the guardian of a toddler about foods that will minimize the risk of aspiration. Which of the following foods should the nurse suggest?
Oranges slices. -This food is soft and easily chewable by children in this age group.
A nurse is planning care for a child who is postoperative following a below-the-knee amputation. Which of the following interventions should the nurse include in the plan of care?
Perform active and isotonic range of motion exercises. - Range of motion exercises of the joints above the amputation site several times per day. This will maintain joint mobility, which is necessary for future ambulation.
A nurse is teaching about injury prevention to the parent of a toddler. Which of the following safety measures should the nurse include in the teaching?
Place a throw rug under the crib. -The toddler can fall out the crib. The nurse should also instruct the parent to move the toddler to a youth bed when they are able to climb out of the crib.
A home health nurse is developing a plan of care for the parents of a toddler who has hemophilia A. Which of the following instructions should the nurse include?
Place knee pads on the child. hemophilia - blood clotting disorder; blood does not clot properly -Take measures to make the environment safe. This can include measures such as installing carpet over ceramic tiled floors or placing knee and elbow pads on the child to protect the Childs joints form injury and bleeding.
A nurse is providing teaching about car seat safety to the parents of an infant. Which of the following instructions should the nurse include?
Place the car seat in a rear facing position until the child is at least 2 years old. -And until the child has exceeded the height and weight limits of the care seat. This position minimizes the stress on the neck by spreading the forces of a frontal crash over the entire head, neck, and back. • Use an approved rear-facing car seat in the back seat, preferably in the middle (away from air bags and side impact), to transport the newborn. • Keep infants in rear-facing car seats until age 2 or until the child reaches the maximum height and weight for the seat.
A nurse is planning to obtain a rectal temperature from a toddler. Which of the following actions should the nurse take?
Place the child in prone position. -The nurse should place the child in a side-lying, Sim's or prone position to obtain a rectal temperature. Sim's Position - The Sims position is a standard position in which the patient lies on their left side, with right hip and knees bent. The lower arm is behind the back, the thighs flexed. The left knee is slightly tilted. The right arm is positioned comfortably in front of the body, the right arm is rested behind the body. Prone - In prone positioning, patients lie on their abdomen
A nurse is providing teaching about home safety to the parents of an infant. Which of the following statements should the nurse make?
Place your infant on a firm mattress for sleeping. -Place infant in a supine position on a firm mattress for sleeping. This decease the risk for suffocation.
A nurse is caring for an infant immediately following surgical repair of a cleft lip. Which of the following actions should the nurse take?
Position the infant on their right side when sleeping. -Right side or upright in an infant seat when sleeping to allow mouth secretions to drain forward. Do not allow infant to turn on their abdomen because this could put pressure on the suture line.
A nurse in an emergency department is caring for a child who has ingested kerosene. The child is lethargic, grunting, and gagging. Which of the following actions should the nurse take?
Prepare for intubation with a cuffed endotracheal tube. -Anticipate that the child will require intubation with a cuffed endotracheal tube because of the high risk of aspiration. This child is at risk for aspiration because they are lethargic, grunting, and gagging.
A nurse in a emergency department is caring for a child who is experiencing an acute asthma attack. Which of the following findings is the priority for the nurse to report to the provider?
Profuse sweating -Indicates that his child is at risk for severe respiratory distress as a result of status asthmaticus and requires immediate intervention. Other manifestations that should be reported immediately include nasal flaring, distended neck veins, and tachypnea. The nurse should remain with the child to provide support and interventions if intubation becomes necessary.
A nurse is planning care for an adolescent client who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions is the nurse's priority?
Promoting bed rest. - Has a higher requirement of cellular oxygenation. Therefore, the nurse should reduce the clients metabolic demands for oxygen and limit cardiac oxygen consumption by encouraging rest.
A nurse is caring for an infant who has respiratory syncytial virus (RSV) and is experiencing respiratory distress. Which of the following actions should the nurse take?
Provide heated, high flow nasal cannula therapy (HHFNC). -This therapy can prevent respiratory failure. HHFNC is a form of humidified oxygen administration which provides continuous positive pressure.
A nurse is providing home care instructions to the parents of a child who is in the edema phase of nephrotic syndrome. Which of the following instructions should the nurse include in the teaching?
Provide quite activities for the child. ➡ Provide quite activities, such as reading and coloring, during edema phase of nephritis to minimize oxygen consumption and preserve energy. • Kidney Failure (nephrotic syndrome); kidney cannot remove waist and balance fluids
A nurse is providing teaching to the parent of an adolescent who has mononucleosis. Which of the following instructions should the nurse include?
Provide your child with medications in an elixir preparation. -Might have a severe sore throat. Therefore, Elixir medications are easier to swallow when experiencing a sore throat.
A nurse is evaluating an adolescent who is postoperative and is receiving fentanyl via an epidural catheter. Which of the following findings should the nurse recognize as a complication?
Respiratory rate of 14/min -Expected reference range for respiratory rate is 16 to 20/min. Fentanyl - Opioid Agonist; used to reduce pain by attaching to receptor in CNS altering perception and response to pain!
A nurse is providing discharge teaching to the guardian of a preschooler who is receiving rehydration therapy for acute diarrhea. Which of the following dietary recommendations should the nurse make?
Steamed broccoli -Early introduction of nutrient dense foods, such as steamed broccoli, can decrease the severity and duration of the illness.
A nurse is caring for a 6 month old infant who has acute vomiting and diarrhea. Which of the following manifestations should the nurse identify as an indication of moderate hypovolemia?
Tachypnea -A hypovolemia worsens, breathing becomes hyperpneic. ➡ hypovolemia (isotonic fluid deficit) - is lack of both water and electrolytes, causing a decrease in circulating blood volume. VITAL SIGNS: Hypothermia, tachycardia (in an attempt to maintain a normal blood pressure), thready pulse, hypotension, orthostatic hypotension, decreased central venous pressure, tachypnea (increased respirations to compensate for lack of fluid volume within the body), hypoxia
A nurse is preparing to perform an orogastric feeding for an infant. Which of the following actions should the nurse take to verify tube placement?
Test gastric secretions of pH. -Test gastric secretions of pH to verify that the orogastric tube is in the stomach. A pH of 5 or less indicates that the orogastric tube is in the stomach, whereas a pH of greater than 5 does not indicate that the tube is in the stomach. Performing orogastric feeding when the tube is not in the stomach increases the risk for aspiration. • Nasogastric (NG) tubes or Orogastric (OG) tubes are small tubes placed either through the nose or the mouth and end with the tip in the stomach. NG/OG tubes may be used for feedings, medication administration, or removal of contents from the stomach via aspiration, suction, or gravity drainage.
A nurse is evaluating the effectiveness of a treatment plan for a school age child who has ADHD. Which of the following findings should the nurse identify as an indication that the treatment plan has been effective?
The child completes homework assignments on time.
A nurse is assessing a 4-month-old infant at a well child visit. Which of the following findings should the nurse expect?
The infant has an absent grasp reflex. -The nurse should expect the infant to grasp objects with both hands at this stage of development.
A nurse in an emergency department is providing pre-procedure teaching to the parents of a child who is to undergo a bronchoscopy due to aspiration of a foreign body. Which of the following parents statements indicate understanding of the teaching?
The provider will remove the object during this procedure. -The provider is able to make a definitive diagnosis of objects in the larynx and trachea during a bronchoscopy and can subsequently remove the foreign body.
A nurse is teaching a female adolescent who reports frequent urinary tract infections. Which of the following instructions should the nurse include in the teaching?
Void at least every 3-4 hrs. -Urinate as soon as they feel the urge and to avoid waiting to void. Urinary stasis increase the risk for infection.
A nurse is performing an initial physical examination on a child. The nurse should recognize that which of the following manifestations indicates a possible brain tumor? SATA
Vomiting Clumsiness Irritability Persistent HA - It tends to become progressively more projectile and is most severe in the AM. It can be accompanied by nausea and is a result of increased IC. -Lack of coordination, and loss of balance are common manifestation of brain tumors. Manifestations results from pressure and interference with circulation within the brain. -Common behavioral manifestation of brain tumors. Other manifestations include anorexia, fatigue, lethargy, and bizarre behavior such as staring. -HA results from pressure on pain-sensitive areas, such as large blood vessels and cranial nerves. HA tend to be worse in the morning and subside as the day progresses.
A nurse on a pediatric unit is admitting a 5-year-old child who has submersion injury and is awake and alert. The parent asks the nurse why the child needs to stay in the facility. Which of the following responses should the nurse make?
We need to observe your child for cerebral swelling. -Still at risk for a complication from the submersion injury (drowning). Complications can include respiratory compromise and cerebral edema during the first 24hrs after the submersion.
A nurse is providing teaching about magnetic resonance imaging (MRI) without contrast to the parent of a child who has cancer. Which of the following statements should the nurse make?
You can remain in the room with your child during the procedure. -Provides comfort and reassurance during the procedure.
A nurse is providing pre-procedure teaching to the parents of a preschooler who has nephrotic syndrome and is scheduled for a percutaneous renal biopsy. Which of the following statements should the nurse include?
Your child will have a pressure dressing on the biopsy site following the test. -To minimize bleeding. The nurse also might use a sandbag to maintain pressure to the puncture site.
A nurse is caring for a child who has terminal leukemia. The parents asks the nurse, "When will we know that our child is nearing the end of their life?" Which of the following statements should the nurse make?
Your child will lose movement in their legs. ➡ Lose movement in the lower extremities. This progressive loss of movement will move up the body as death nears. • Leukemias are cancers of white blood cells or of cells that develop into white blood cells. In leukemia, the white blood cells are not functional. They invade and destroy bone marrow, and they can metastasize to the liver, spleen, lymph nodes, testes, and brain.
