306 Practice A

A nurse is receiving change of shift report on four children. Which of the following children should the nurse assess first?

A toddler who has a concussion and an episode of forceful vomiting

A nurse in the ED is caring for an adolescent who has severe abd pain due to appendicitis. Which of the following locations is McBurney's point?

A- RLQ

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

Absence of peristalsis

A nurse is creating a plan of care for a toddler who has minimal change nephrotic syndrome (MCNS) and 3+ pitting edema. Which of the following interventions should the nurse include in the plan?

Administer corticosteroids to the toddler

A nurse is providing discharge teaching to the parents of a 3mo infant following a cheiloplasty. Which of the following instructions should the nurse include?

Apply a thin layer of antibiotic ointment on your baby's suture line for the next 3 days.

A nurse is assessing the pain level of a 3yo toddler. Which of the following pain assessment scales should the nurse use?

FACES pain rating scale

A nurse is providing teaching to an adolescent about how to manage tinea pedis. Which of the following statements by the adolescent indicates an understanding of the teaching?

I should wear sandals as much as possible

A nurse in an ED is caring for a school-age child who is experiencing an anaphylactic reaction. Which of the following is the priority action by the nurse?

Administer IM epinephrine to the child

A nurse is performing hearing screenings for children at a community health fair. Which of the following children should the nurse refer to a provider for a more extensive hearing evaluation?

An infant who is 8mo and not yet making babbling sounds

A nurse is providing teaching to the parent of a school-age child who has oral candidiasis and is to begin taking oral nystatin. Which of the following instructions should the nurse include?

Shake the medication prior to administration

A nurse is caring for a 10yo child following a head injury. Which of the following findings should the nurse ID an and indication that the child is developing DI?

Sodium 155 mEq/L

A nurse in the ED is caring for a toddler who has partial-thickness burns on his R arm. Which of the following actions should the nurse take?

Cleanse the affected area with mild soap and water

A nurse is providing discharge teaching to the parent of an 18 mo toddler who has dehydration as a result of acute diarrhea. Which statement by the parent indicates understanding of teaching

I will monitor my child's number of wet diapers

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

Sodium 140 mEq/L

A nurse is auscultating the lungs of an adolescent who has asthma. The nurse should ID the sound as which of the following? (Audio clip).

Tachypnea

A nurse is reviewing the lab report of a school-age child who is experiencing fatigue. Which of the following findings should the nurse recognize as an indication of anemia?

Hematocrit 28%

A nurse in an emergency department is performing a physical assessment on a 2wk old male infant. Which of the following manifestations is the priority for the nurse to report to the provider?

Substernal retractions

A nurse in an ED is assessing a 3mo infant who has rotavirus and is experiencing acute vomiting and diarrhea. Which of the following manifestations should the nurse ID as an indication that the infant has moderate to sever dehydration?

Sunken anterior fontanel

A nurse is caring for a preschooler who has been receiving IV fluids via peripheral IV catheter. When prepping to discontinue IV fluids and catheter, which of the following actions should the nurse plan to take?

1. Turn off IV pump 2. Occlude IV tubing 3. Remove tape securing catheter 4. Apply pressure over catheter site

A nurse is reviewing the dietary choices of an adolescent who has iron deficiency anemia. The nurse should ID what which of the following menu items has the highest amount of iron?

1/2 cup of raisins

A nurse is preparing to administer ibuprofen 5mg/kg Q 6hr for temp above 38C to an infant who weighs 17.6lbs. The infant has a temp of 38.4C. Available is ibuprofen liquid 100mg/5ml. How many ml should the nurse administer per dose?

2 ml

A nurse is providing teaching to the parents of a preschooler who has heart failure and who is to begin taking digoxin BID. Which of the following instructions should the nurse include in the teaching?

Brush the child's teeth after giving the medication

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

Dry, hacking cough

A nurse is providing teaching to the family of a school-aged child who has juvenile idiopathic arthritis. which of the following instructions should the nurse include in the teaching?

Encourage the child to perform independent self-care

A nurse in the ED is caring for a school-age child who has epiglottitis. Which of the following actions should the nurse take?

Monitor the child's O2 sat

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?

Perform a finger stick

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

Playing dress up

A nurse is assessing a client who has a new dx of celiac disease. Which of the following clinical manifestations should the nurse expect?

Steatorrhea

A nurse is assessing an adolescent who received a sodium polystyrene sulfonate enema. Which of the following findings indicates effectiveness of the medication?

The child's serum potassium level is 4.1 mEq/L

A nurse is assessing a 3yo toddler at a well-child visit. Which of the following manifestations should the nurse report to the provider?

Resp rate 45/min

A nurse is providing dietary teaching to the parent of a school-age child who has celiac disease. The nurse should recommend that the parent offer which of the following foods to the child?

Rice pudding

A nurse is planning care for a toddler who has a serum lead level of 4mcg/dL. Which of the following actions should the nurse plan to take?

Schedule the toddler for a yearly rescreening

A nurse caring for a school-age child who has primary nephrotic syndrome is taking prednisone. Following 1 week of treatment, which of the following clinical manifestations indicates to the nurse that the medication is effective?

Decreased edema

A nurse in a provider's office is preparing to administer immunizations to a toddler during a well-child visit. Which of the following actions should the nurse plan to take? (Exhibit attached).

Withhold MMR vaccine

A nurse is preparing an adolescent for a lumbar puncture. Which of the following actions should the nurse take?

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

A nurse is creating a plan of care for a preschooler who has Wilms' tumor and is scheduled for surgery. Which of the following interventions should the nurse include?

Avoid palpating the abdomen when bathing the child before surgery

A school nurse is assessing a school-age child's BP while he is seated in a chair. The child starts to experience a tonic-clonic seizure. Which of the following actions should the nurse take first?

Assist the child to a side-lying position on the floor

A nurse caring for a 15yo following a head injury. Which of the following findings should the nurse ID as an indication that the child is developing syndrome of inappropriate antidiuretic hormone secretion (SIADH)?

Mental confusion

A nurse is teaching the parents of a school-aged child who has a new diagnosis of osteomyelitis of the tibia. The nurse should ID that which of the following statements by the parents indicates an understanding of the teaching?

My child will receive abx for several weeks

A nurse is assessing an infant who has pneumonia. Which of the following findings is the priority for the nurse to report to the provider?

Nasal flaring

A nurse is providing discharge teaching to the parent of a school-age child who has moderate persistent asthma. Which of the following instructions should the nurse include?

PFTs will be performed every 12-24 months to evaluate how your child is responding to therapy

A nurse is caring for a school-age child who has peripheral edema. Which of the following assessments should the nurse perform to confirm peripheral edema?

Palpate the dorsum of the child's feet

A nurse in a provider's office is caring for a school-age child who has varicella. The parent asks the nurse when her child will not longer be contagious. Which of the following responses should the nurse make?

When your child's lesions are crusted, 6 days after they appear

A nurse is teaching the parents of a child who has a cognitive impairment about toilet training. Which of the following instructions should the nurse include in the teaching?

Award the child with a sticker when he sits on the potty chair

A nurse is caring for a toddler who has spastic (pyramidal) cerebral palsy. Which of the following clinical manifestations should the nurse expect?

- Ankle clonus - Exaggerated stretch reflexes - Contractures

A nurse is creating an education plan to teach parents about protecting their children from sunburns. Which of the following instructions should the nurse plan to include?

Choose a waterproof sunscreen with an SPF of at least 15

A nurse is teaching the parent of a newborn about ways to prevent SIDS. Which of the following instructions should the nurse include?

Give the infant a pacifier at bedtime

A nurse is providing teaching about car seat use to the mother of a 6mo infant. Which of the following statements by the mother indicates an understanding of the teaching?

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

A nurse is creating a plan of care for an infant who has an epidural hematoma with a skull fracture. Which of the following actions should the nurse include in the plan?

Implement seizure precautions for the infant

A nurse is planning developmental activities for a newly admitted 10yo child who has neutropenia. Which of the following actions should the nurse plan to take?

Provide the child with a book about adventure

A nurse is providing dietary teaching to the parent of a school-age child who has CF. Which of the following statements should the nurse make?

You should offer your child high-protein meals and snacks throughout the day

A nurse is caring for a hospitalized preschooler. The child's mother is going home for a few hours while another relative stays with the child. Which of the following statements should the nurse make to explain to the child when her mother will return?

Your mommy will be back after you eat

A nurse is creating a plan of care for a newly admitted adolescent who has bacterial meningitis. How long should the nurse plan to maintain the adolescent in droplet precautions?

For 24hr following initiation of antimicrobial therapy

A nurse caring for a preschooler who is scheduled for hydrotherapy tx for wound debridement following a burn injury. Which of the following actions should the nurse take prior to the procedure?

Administer an analgesic to the child

A nurse is preparing to administer an immunization to a 4yo child. Which of the following actions should the nurse plan to take?

Administer the immunization using a 24 gauge needle

A nurse is providing anticipatory guidance to the mother of a toddler. Which of the following expected behavior characteristics of toddlers should the nurse include in the teaching?

Expresses likes and dislikes

A charge nurse in an ED is preparing an in-service for a group of newly licensed nurses on the clinical manifestations of child maltreatment. Which of the following clinical manifestations should the charge nurse include as suggestive of potential physical abuse?

Symmetric burns of the lower extremities

A nurse is providing teaching to the parents of a toddler about the administration of prescribed eye drops and eye ointment. Which of the following instructions should the nurse include?

Administer the eye drops 3 minutes before the ointment

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

Temp 39.1C (102.4F)

A school nurse is assessing an adolescent who presents with multiple burns in various stages of healing. Which of the following behaviors should the nurse ID as suggestive of possible physical abuse?

Denies discomfort during assessment of injuries.