Week 11

Q5. The nurse is closely monitoring the intake and output of an infant with heart failure who is receiving diuretic therapy. The nurse should use which most appropriate method to assess the urine output? 1. Weighing the diapers 2. Inserting a Foley catheter 3. Comparing intake with output 4. Measuring the amount of water added to formula

1. Weighing the diapers

Q8. Antibiotics are prescribed for a child with otitis media who underwent a myringotomy with insertion of tympanostomy tubes. The nurse provides discharge instructions to the parents regarding the administration of the antibiotics. Which statement, if made by the parents, indicates understanding of the instructions provided ? 1. "Administer the antibiotics until they are gone and full course needs to be completed as prescribed." 2. "Administer the antibiotics if the child has a fever." 3. "Administer the antibiotics until the child feels better." 4. "Begin to taper the antibiotics after 3 days of a full course."

1. "Administer the antibiotics until they are gone and full course needs to be completed as prescribed."

Q7. The nurse is caring for a child after a tonsillectomy. The nurse monitors the child, knowing that which finding indicates the child is bleeding ? 1. Frequent swallowing 2. A decreased pulse rate 3. Complaints of discomfort 4. An elevation in blood pressure

1. Frequent swallowing

Q10. The nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by respiratory syncytial virus (RSV). Which interventions should the nurse include in the plan of care? Select all that apply. 1. Place the infant in a private room. 2. Ensure that the infant's head is in a flexed position. 3. Wear a mask at all times when in contact with the infant. 4. Place the infant in a tent that delivers warm humidified air. 5. Position the infant on the side, with the head lower than the chest. 6. Ensure that nurses caring for the infant with RSV do not care for other high-risk children

1. Place the infant in a private room. 6. Ensure that nurses caring for the infant with RSV do not care for other high-risk children

Q10. A child has been diagnosed with acute otitis media (AOM) of the right ear. Which interventions should the nurse include in the plan of care ? Select all that apply. 1. Provide a soft diet. 2. Position the child on the left side. 3. Administer an antihistamine twice daily. 4. Irrigate the right ear with normal saline every 8 hours. 5. Administer ibuprofen (Motrin IB) for fever every 4 hours as prescribed and as needed. 6. Instruct the parents about the need to administer the prescribed antibiotics for the full course of therapy.

1. Provide a soft diet. 5. Administer ibuprofen (Motrin IB) for fever every 4 hours as prescribed and as needed. 6. Instruct the parents about the need to administer the prescribed antibiotics for the full course of therapy.

Q7. The nurse has provided home care instructions to the parents of a child who is being discharged after cardiac surgery. Which statement made by the parents indicates a need for further instructions? 1. "A balance of rest and exercise is important." 2. "I can apply lotion or powder to the incision if it is itchy." 3. "Activities in which my child could fall need to be avoided for 2 to 4 weeks." 4. "Large crowds of people need to be avoided for at least 2 weeks after surgery."

2. "I can apply lotion or powder to the incision if it is itchy."

Q1. A 10-year-old child with asthma is treated for acute exacerbation in the emergency department. The nurse caring for the child should monitor for which sign, knowing that it indicates a worsening of the condition? 1. Warm, dry skin 2. Decreased wheezing* 3. Pulse rate of 90 beats/minute 4. Respirations of 18 breaths/minute

2. Decreased wheezing* * Decreased wheezing in a child with asthma may be interpreted incorrectly as an improving sign when it may actually signal an inability to move air. "A silence chest" is a worsening sign during an asthma episode. With treatment, increased wheezing actually may signal that the child's condition is improving.

Q9. The nurse is caring for an infant with bronchiolitis, and diagnostic tests have confirmed respiratory syncytial virus (RSV). On the basis of this finding, which is the most appropriate nursing action? 1. Initiate strict enteric precautions. 2. Move the infant to a room with another child with RSV. * 3. Leave the infant in the present room because RSV is not contagious. 4. Inform the staff that they must wear a mask, gloves, and a gown when caring for the child.

2. Move the infant to a room with another child with RSV. * *RSV is a highly communicable disorder and is not transmitted via the airborne route. The virus usually is transferred by the hands so use of contact and standard precautions during care is necessary. Using good hand washing techniques and wearing gloves and gowns are also necessary. Masks are not required. An infant with RSV is isolated in a single room or placed in a room with another child with RSV.

Q2. The mother of a 6-year-old child arrives at a clinic because the child has been experiencing scratchy, red, and swollen eyes. The nurse notes a discharge from the eyes and sends a culture to the laboratory for analysis. Chlamydial conjunctivitis is diagnosed. On the basis of this diagnosis, the nurse determines that which requires further investigation? 1. Possible trauma 2. Possible sexual abuse 3. Presence of an allergy 4. Presence of a respiratory infection

2. Possible sexual abuse

Q4. The nurse is reviewing the laboratory results for a child scheduled for tonsillectomy. The nurse determines that which laboratoy value is most significant to review? 1. Creatinine level 2. Prothrombin time 3. Sedimentation rate 4. Blood urea nitrogen level

2. Prothrombin time

Q5. The nurse is preparing to care for a child after a tonsillectomy. The nurse documents on the plan of care to place the child in which position ? 1. Supine 2. Side-lying 3. High Fowler's 4. Trendelenburg's

2. Side-lying

Q6. After a tonsillectomy, the nurse reviews the health care provider's (HCP's) postoperative prescriptions. Which prescription should the nurse question ? 1. Monitor for bleeding. 2. Suction every 2 hours. 3. Give no milk or milk products. 4. Give clear, cool liquids when awake and alert

2. Suction every 2 hours.

Q9. The day care nurse is observing a 2-year-old child and suspects that the child may have strabismus*. Which observation made by the nurse indicates the presence of this condition ? 1. The child has difficulty hearing. 2. The child consistently tilts the head to see. 3. The child does not respond when spoken to. 4. The child consistently turns the head to hear.

2. The child consistently tilts the head to see. * Strabismus is a condition in which the eyes are not aligned becaused of lack of coordination of the extraocular muscles.

Q5. The emergency department nurse is caring for a child diagnosed with epiglottitis. In assessing the child, the nurse should monitor for which indication that the child may be experiencing airway obstruction? 1. The child exhibits nasal flaring and bradycardia. 2. The child is leaning forward, with the chin thrust out. 3. The child has a low-grade fever and complains of a sore throat. 4. The child is leaning backward, supporting himself or herself with the hands and arms.

2. The child is leaning forward, with the chin thrust out.

Q1. After a tonsillectomy, a child begins to vomit bright red blood. The nurse should take which initial action? 1. Maintain NPO status. 2. Turn the child to the side. 3. Administer the prescribed antiemetic. 4. Notify the health care provider (HCP)

2. Turn the child to the side.

Q7. The clinic nurse reads the results of a tuberculin skin test (TST) on a 3-year-old child. The results indicate an area of induration measuring 10 mm. The nurse should interpret these results as which finding? 1. Positive 2. Negative 3. Inconclusive 4. Definitive and requiring a repeat test

3. "Antibiotics are not indicated unless a bacterial infection is present."

Q8. The mother of a hospitalized 2-year-old child with viral laryngotracheobronchitis (croup) asks the nurse why the health care provider did not prescribe antibiotics. Which response should the nurse make? 1. "The child may be allergic to antibiotics." 2. "The child is too young to receive antibiotics." 3. "Antibiotics are not indicated unless a bacterial infection is present." 4. "The child still has the maternal antibodies from birth and does not need antibiotics."

3. "Antibiotics are not indicated unless a bacterial infection is present."

Q3. The nurse prepares a teaching plan for the mother of a child diagnosed with bacterial conjunctivitis. Which, if stated by the mother, indicates a need for further teaching? 1. "I need to wash my hands frequently." 2. "I need to clean the eye as prescribed." 3. "It is okay to share towels and washcloths." 4. "I need to give the eye drops as prescribed."

3. "It is okay to share towels and washcloths."

Q3. On assessment of a child admitted with a diagnosis of acute-stage Kawasaki disease, the nurse expects to note which clinical manifestation of the acute stage of the disease? 1. Cracked lips 2. Normal appearance 3. Conjunctival hyperemia 4. Desquamation of the skin

3. Conjunctival hyperemia

Q6. The clinic nurse reviews the record of a child just seen by a health care provider and diagnosed with suspected aortic stenosis. The nurse expects to note documentation of which clinical manifestation specifically found in this disorder? 1. Pallor 2. Hyperactivity 3. Exercise intolerance 4. Gastrointestinal disturbances

3. Exercise intolerance

Q10. Assessment findings of an infant admitted to the hospital reveal a machinery-like murmur on auscultation of the heart and signs of heart failure. The nurse reviews congenital cardiac anomalies and identifies the infant's condition as which disorder? Refer to figure (the circled area) to determine the condition. 1. Aortic stenosis 2. Atrial septal defect 3. Patent ductus arteriosus 4. Ventricular septal defect

3. Patent ductus arteriosus

Q1. The nurse is monitoring an infant with congenital heart disease closely for signs of heart failure (HF). The nurse should assess the infant for which early sign of HF? 1. Pallor 2. Cough 3. Tachycardia 4. Slow and shallow breathing

3. Tachycardia

Q3. A new parent expresses concern to the nurse regarding sudden infant death syndrome (SIDS). She asks the nurse how to position her new infant for sleep. In which position should the nurse tell the parent to place the infant? 1. Side or prone 2. Back or prone 3. Stomach with the face turned 4. Back rather than on the stomach

4. Back rather than on the stomach

Q8. A child with rheumatic fever will be arriving in the nursing unit for admission. On admission assessment, the nurse should ask the parents which question to elicit assessment information specific to the development of rheumatic fever? 1. "Has the child complained of back pain?" 2. "Has the child complained of headaches?" 3. "Has the child had any nausea or vomiting?" 4. "Did the child have a sore throat or fever within the last 2 months?"

4. "Did the child have a sore throat or fever within the last 2 months?"

Q4. The nurse provides home care instructions to the parents of a child with heart failure regarding the procedure for administration of digoxin (Lanoxin). Which statement made by the parent indicates the need for further instruction? 1. "I will not mix the medication with food." 2. "I will take my child's pulse before administering the medication." 3. "If more than one dose is missed, I will call the health care provider." 4. "If my child vomits after medication administration, I will repeat the dose."

4. "If my child vomits after medication administration, I will repeat the dose."

Q4. The clinic nurse is providing instructions to a parent of a child with cystic fibrosis regarding the immunization schedule for the child. Which statement should the nurse make to the parent? 1. "The immunization schedule will need to be altered." 2. "The child should not receive any hepatitis vaccines. " 3. "The child will receive all the immunizations except for the polio series." 4. "The child will receive the recommended basic series of immunizations along with a yearly influenza vaccination."

4. "The child will receive the recommended basic series of immunizations along with a yearly influenza vaccination."

Q2. The nurse reviews the laboratory results for a child with a suspected diagnosis of rheumatic fever, knowing that which laboratory study would assist in confirming the diagnosis? 1. Immunoglobulin 2. Red blood cell count 3. White blood cell count 4. Anti-streptolysin O titer

4. Anti-streptolysin O titer

Q2. The mother of an 8-year-old child being treated for right lower lobe pneumonia at home calls the clinic nurse. The mother tells the nurse that the child complains of discomfort on the right side and that ibuprofen (Motrin IB) is not effective. Which instruction should the nurse provide to the mother? 1. Increase the dose of ibuprofen. 2. Increase the frequency of ibuprofen. 3. Encourage the child to lie on the left side. 4. Encourage the child to lie on the right side.

4. Encourage the child to lie on the right side.

Q6. A child with laryngotracheobronchitis (croup) is placed in a cool mist tent. The mother becomes concerned because the child is frightened, consistently crying and trying to climb out of the tent. Which is the most appropriate nursing action? 1. Tell the mother that the child must stay in the tent. 2. Place a toy in the tent to make the child feel more comfortable. 3. Call the health care provider and obtain a prescription for a mild sedative. 4. Let the mother hold the child and direct the cool mist over the child's face.

4. Let the mother hold the child and direct the cool mist over the child's face.

Q9. A health care provider has prescribed oxygen as needed for an infant with heart failure. In which situation should the nurse administer the oxygen to the infant? 1. During sleep 2. When changing the infant's diapers 3. When the mother is holding the infant 4. When drawing blood for electrolyte level testing

4. When drawing blood for electrolyte level testing