Adaptive Quizzes
A nurse is reinforcing care instructions with the parent of a child who has a newly placed gastrostomy tube. Which of the following statements demonstrates an understanding of the instructions? A. " should maintain a steady pull on the G tube during feedings." B. " should flush the tube with water in between administering each medicine." C. " should aspirate before each feeding to be certain the tube is in the correct place." D. "I should use half-strength hydrogen peroxide to clean the site until the skin has healed."
B. " should flush the tube with water in between administering each medicine." Incorrect Answers: A. Excessive pulling on the gastrostomy tube can lead to enlargement of the opening on the abdomen and subsequent leaking of highly irritating gastric fluids onto the skin. The tubing should be firmly secured to the abdomen with tape or a commercial device to prevent tension at the exit site. C. This intervention is not necessary when the child has a gastrostomy tube. The tube has been surgically placed through the abdominal wall directly into the stomach. D. The use of hydrogen peroxide to cleanse the gastrostomy tube site has been linked to the formation of red, moist tissue overgrowth referred to as granulation tissue. This moist tissue is irritating to healthy tissue.
A nurse is reviewing the dynamics of a family in which abuse is suspected. Which of the following findings should the nurse report to the provider? A. The parents provide emotional support to the child during the assessment process. B. The child has several unexplained scars and bruises. C. The child cries and appears afraid of the health care provider. D. The parents offer consistent, detailed stories about the child's injuries.
B. The child has several unexplained scars and bruises. Incorrect Answers: A. Parents providing emotional support to the child is an expected finding. An unexpected finding would be the parents showing no emotion at all toward the child. C. A fear of health care staff is an expected finding in a child. An unexpected finding would be the child showing indiscriminate friendliness toward strangers such as the health care provider. D. Parents offering consistent stories about the child's injuries is an expected finding. An unexpected finding would be the parents presenting conflicting stories about the injury.
A nurse in an acute care unit is caring for an adolescent who has an exacerbation of cystic fibrosis. The adolescent has 5 younger siblings at home and reports to the nurse that his parents have not brought the siblings to visit. Which of the following responses should the nurse make? A. "You should ask your parents to bring them to visit individually." B. "Why do you think they haven't brought your siblings in to visit?" C. "Are you concerned because your parents haven't brought your siblings to visit you?" D. "I know it is hard, but you can see them all when you go home in a few days."
C. "Are you concerned because your parents haven't brought your siblings to visit you?" In this scenario, the nurse responds by paraphrasing, which is a therapeutic communication technique used to demonstrate concern and ensure the nurse correctly understands the client's concern. Incorrect responses : A. This response gives a personal opinion, which is a nontherapeutic communication technique. The nurse does not know the client's home situation or if bringing the siblings to visit individually would create a hardship. B. This response asks a "why" question, which is a nontherapeutic communication technique that can evoke a defensive client response. D. This response provides false reassurance and minimizes the client's concern, which is nontherapeutic communication technique.
A nurse is caring for a child who has a tracheostomy. Which of the following techniques should the nurse use to suction the child's tracheostomy? A. Insert the catheter to 2 cm (0.79 in) beyond the end of the tracheostomy tube B. Remove the catheter while applying intermittent suction C. Instill 0.9% sodium chloride irrigation to loosen secretions while suctioning D. Continue suctioning until the secretions are removed
Correct Answer: B. Remove the catheter while applying intermittent suction. The nurse should insert the catheter without suction and then withdraw the catheter while applying intermittent suction. Incorrect Answers: A. The nurse should insert the catheter 0.5 cm (0.2 in) beyond the end of the tracheostomy tube. C. The nurse should avoid the routine instillation of 0.9% sodium chloride irrigation for suctioning. D. The nurse should limit suctioning to no more than 3 aspirations at a time.
A nurse is applying EMLA cream to a child's hand prior to the insertion of an intravenous catheter. Which of the following interventions should the nurse perform? A. Apply the EMLA cream 60 minutes prior to the procedure B. Cleanse the site with alcohol prior to applying the cream C. Rub the cream into the skin using firm pressure in a circular motion D. Choose another site if the skin area becomes reddened or blanched
Correct Answer: A. Apply the EMLA cream 60 minutes prior to the procedure: EMLA cream is a topical anesthetic that should be applied at least 60 minutes prior to a procedure. Procedures requiring deeper penetration such as a bone marrow aspiration may require application 2 to 3 hours prior to the scheduled procedure. Incorrect Answers: B. The site should only be cleaned with soap and water prior to the application of the EMLA cream. The medication requires the presence of alcohol on the skin to activate the h anesthetic action. C. The cream should be placed over the intended area, and an occlusive dressing should be applied. The nurse should not rub the cream into the skin. D. Reddened or blanched skin is an expected finding when the anesthetic medication has effectively penetrated the skin.
A nurse is caring for a preschooler who has a terminal illness. The nurse should expect the preschooler to have which of the following perspectives about death? A. Believes that her own thoughts can cause death B. Has an understanding of the finality of death C. Exhibits curiosity about what happens to the body after death D. Views funeral services as unnecessary
Correct Answer: A. Believes that her own thoughts can cause death The nurse should expect preschoolers to believe that their own thoughts or actions can cause death, and they might believe that death is a punishment tor wrong-doing. Incorrect Answers: B. The nurse should expect a preschooler to view death as a temporary occurrence like sleeping. The preschooler might believe the person can "wake up" again. C. The nurse should expect a school aged child to be curious abut what happens to a body following death. D. The nurse should expect an adolescent to reject traditions surrounding death such as funeral services as unnecessary or unimportant.
A nurse is collecting data from a toddler who has a history of asthma. Which of the following findings should de nurse report to the provider? A. Inspiration phase that is longer than the expiration phase B. Intercostal retractions C. Vesicular breath sounds upon auscultation D. Rise and fall of the abdomen during respirations
Correct Answer: B. Intercostal retractions. The presence of intercostal retractions signifies that the toddler is utilizing accessory muscles for respirations. This finding should be immediately reported to the provider. Incorrect Answers: A. This respiratory pattern is an expected finding and does not require notification of the health care provider. C. Vesicular breath sounds are an expected finding in a toddler who has a history of asthma. These are soft, low-pitched sounds heard over the outer margins of the lungs. D. This is an expected pattern of respirations during the infant and toddler years and does not require notification of the provider.
A nurse is reinforcing teaching with the guardians of a toddler who has a new prescription for an oral iron supplement. To increase the child's absorption of the iron, the nurse should recommend administering the supplement with which of the following? A. Eggs B. Orange juice C. Milk D. Oatmeal
Correct Answer: B. Orange juice The nurse should recommend that the guardians administer the iron supplement with orange juice or other citrus juices to increase the absorption of iron. Incorrect Answers: A. The nurse should inform the guardians that protein does not increase the absorption
A nurse is caring for a toddler who has otitis media and a temperature of 39.1°C (102.4°F). Which of the following actions should the nurse take first? A. Reduce the temperature of the child's room B. Redress the child in minimal clothing C. Apply cool compresses to the child's forehead D. Administer an antipyretic to the child
Correct Answer: D. Administer an antipyretic to the child When using the urgent vs. nonurgent approach to client care, the nurse should first administer an antipyretic to decrease the toddler's body temperature. Incorrect Answers: A. Reducing the room temperature is an effective method of lowering the toddler's temperature when implemented about 1 hour after the adrinistration of an antipyretic. Therefore, this is not the first action the nurse should take. B. Redressing the child in minimal clothing is an effective method of reducing the C. Applying cool compresses to the toddler's forehead is an effective method of reducing the toddler's temperature when implemented about 1 hour after the administration of an antipyretic. Therefore, this is not the first action the nurse should take.
A nurse is caring for a child who has a vesicular rash for 6 days. The parents of the child ask the nurse what illness caused this rash. The nurse should explain the child has which of the following conditions? A. Measles B. Fifth disease C. Tetanus D. Varicella
Correct Answer: D. Varicella Children who have varicella might present with a maculopapular rash that progresses to vesicles on erythematous bases that eventually rupture and crust over. Incorrect Answers: A. A child who has measles might develop Koplik spots, a transient cephalocaudal rash of maculopapular eruptions of the upper trunk and face. These become more confluent as the rash spreads to the lower areas of the body. B. Fifth disease usually begins with bright red cheeks, producing a "slapped-cheek" appearance. Following this, a rash appears on the extremities and trunk. The rash fades centrally, giving a lacy (reticulated) appearance to the rash. C. A child who has tetanus will develop lockjaw and muscle rigidity; however, there is no rash associated with tetanus. Nurses recommend the DTaP immunization to aid in prevention of this disease.
A school nurse is assisting a child who has been stung by a bee. The child's hand is swelling, and the nurse notes that the child is allergic to insect stings. Which of the following findings should the nurse expect if the child develops anaphylaxis? (Select all that apply.) A. Bradycardia B. Nausea C. Hypertension D. Urticaria
Correct Answers: B. Nausea D. Urticaria E. Stridor Nausea and hives are common responses to excessive histamine release. A serious, life-threatening response to excessive histamine release is airway narrowing, which presents with dyspnea and stridor. Incorrect Answer: A. C. Histamine is a potent vasodilator; therefore, a client who is going into anaphylaxis will exhibit tachycardia and hypotension.
A nurse is reinforcing discharge teaching with a client who is postpartum and plans to breastfeed her infant. Which of the following pieces of information should the nurse reinforce with the client? (Select all that apply.) A. Schedule feedings every 4 hr. B. Offer supplemental formula every other feeding during the first week C. Thaw frozen breast milk with warm water. D. Massage breast milk onto the nipples after breastfeeding. E. Frequent swallowing by the infant indicates adequate suckling.
Correct Answers: C. Thaw frozen breast milk with warm water. D. Massage breast milk onto the nipples after breastfeeding. E. Frequent swallowing by the infant indicates adequate suckling. The nurse should reinforce how to thaw frozen breast milk with warm water or a bottle warmer. The nurse should instruct the client to avoid using a microwave to thaw breast milk because it can decrease the anti infective properties and nutritional value of breast milk. To prevent and treat sore nipples, the nurse should recommend rubbing a small amount of breast milk onto the nipples after breastfeeding.
A nurse is reinforcing teaching about exercise with an adolescent client who has type 1 diabetes mellitus. Which of the following points should the nurse reinforce? A. "Before engaging in physical activity, you should inject insulin into a muscle group that you will be using during the activity." B. "You should plan to alternate days of vigorous physical exercise with days of increased rest. C. "Plan to avoid participation in team sports.. D. "You might need to decrease your routine insulin dosage before exercise."
D. "You might need to decrease your routine insulin dosage before exercise." Eating additional carbohydrate or decreasing the regular insulin injection according to an established protocol before exercise is sometimes necessary to prevent hypoglycemia. Incorrect Answers: A. Exercising a muscle group increases circulation and insulin absorption from that area. Injecting insulin into a muscle that will not be used during the exercise can decrease the chances of hypoglycemia occurring during the physical activity. B. An adolescent who has type 1 diabetes mellitus should design a consistent daily exercise program. Once a daily program is established, the client needs to continue this type of exercise every day, including weekends, to avoid becoming hyperglycemic. C. Exercise is an important component of care for type 1 diabetes mellitus because it uses carbohydrates and helps reduce hyperglycemia. No type of exercise is restricted for adolescents or children who have diabetes mellitus.
A nurse is caring for an infant who is experiencing dehydration. Which of the following data related to hydration status is the nurse's priority to collect? A. Measure the client's weight daily B. Observe tears C. Palpate the fontanel D. Check skin turgor
Correct Answer: A. Measure the client's weight daily The nurse should apply the urgent versus non-urgent priority-setting framework. Using this framework, the nurse should consider urgent findings to be the priority because they more readily indicate the degree of threat to the client. The nurse may also need to use nursing knowledge to identify which finding is the most critical. Daily weights are the most sensitive indicator of fluid balance in clients of all ages. Daily weights are especially critical for infants and children because fluid accounts for a greater portion of body weight. Incorrect Answers: B. Checking for the absence of tears is part of data collection for hydration status. However, the lack of tears does not give the nurse precise information about the degree or severity of the infant's dehydration. Therefore, there is another finding that is the priority. C. Palpating the fontanel is part of collecting data about hydration status. However, unless the fontanel is extremely sunken, this action does not give the nurse precise information about the degree or severity of the infant's dehydration. Therefore, there is another finding that is the priority. D. Checking skin turgor is part of assessing hydration status. However, unless the skin is extremely slow to respond, this observation does not give the nurse precise information about the degree or severity of the infant's dehydration. Therefore, there is another finding that is the priority.
A nurse is caring for a 2-day-old infant who has a myelomeningocele. Which of the following actions should the nurse take? A. Monitor the infant's head circumference B. Position the infant supine C. Place the child under a radiant warmer D. Tape a piece of plastic over the protruding membranes
Correct Answer: A. Monitor the infant's head circumference Infants who have myelomeningocele have an increased risk for hydrocephalus. Measuring the infant's head circumference can help determine any increase. Incorrect Answer: B. The nurse should place a child who has myelomeningocele in a prone position to minimize the risk of trauma or tension to the sac. C. The nurse should not place a child who has myelomeningocele under a radiant warmer due to the risk of drying out the lesion and causing cracking . D. Placing a piece of plastic over the protruding membranes will exert pressure on the area. Instead, the nurse can place wet gauze over the lesion to help provide moisture.
A nurse is planning care for a 4-year-old child who has nephrotic syndrome. Which of the following actions should the nurse include? A. Provide thorough skin care B. Test for blood type and cross-match C. Allow ample hydrating fluids D. Maintain a low-carbohydrate diet
Correct Answer: A. Provide thorough skin care. The nurse should provide thorough skin care for this child who has nephrotic syndrome. Skin care is especially important due to edema and the risk of infection. Incorrect Answers: B. This child is not likely to receive a blood transfusion which is indicated for significant blood loss. C. Fluid restriction might be necessary for a child who has nephrotic syndrome. D. The child's diet might require protein, sodium, and fat restrictions, but there is generally no indication for a low-carbohydrate diet.
A nurse in a pediatric clinic is preparing to administer an IM vaccine to a preschooler. Which of the following actions should the nurse take? A. Ask the preschooler's parents to leave the room before administering the vaccine B. Allow the preschooler to hold a needleless syringe during the vaccine C. Give the preschooler a detailed explanation of the purpose of the vaccine D. Reassure the preschooler that the vaccine will just feel like a bee sting.
Correct Answer: Allow the preschooler to hold a needleless syringe during the vaccine. The nurse should provide opportunities for distraction during the injection such as holding real medical equipment. Other strategies include allowing the preschooler to hold a stuffed animal, small foam ball, bandages, or unopened alcohol swabs. The nurse should give the preschooler choices when possible but avoid excessive delays. Incorrect Answers: A. The nurse should identify that young children gain support from their parents. The presence of a parent can help the preschooler feel a sense of security and comfort. If the parents prefer to leave the room, the nurse should respect and support their decision. However, the nurse should ask the parents to remain close by to offer necessary support for the preschooler following the administration of the vaccine. C. The nurse should use short, simple, and age-appropriate explanations of what to expect prior to administering the vaccine. A detailed explanation of the purpose of the vaccine will likely confuse the preschooler and increase the child's anxiety level. D. The nurse should discuss the procedure with the preschooler using terminology appropriate for this age group. The preschooler might be scared of bees; therefore, comparing the vaccine to a bee sting could potentially cause the child to become frightened.
A nurse is caring for an infant who has tetralogy of Fallot and is experiencing a hypercyanotic spell while crying. Which of the following actions should the nurse take? A. Administer oxygen at 2 L via nasal cannula B. Position the infant in a knee-chest position C. Insert an intravenous catheter D. Instruct the parent to feed the child
Correct Answer: B. Position the infant in a knee-chest position. Placing an infant with tetralogy of Fallot in a knee-chest position will increase systemic vascular resistance. This action will divert more blood to the pulmonary arteries, which will promote oxygenation in the infant. Incorrect Answers: A. The nurse should administer 100% oxygen via facemask to an infant who is experiencing a hypercyanotic spell. C. This action would not be appropriate during a hypercyanotic spell. Inserting an intravenous catheter would cause further agitation in the infant and prolong the hypercyanotic spell. D. Feeding the child would not be an appropriate action while the infant is experiencing a hypercyanotic spell. The nurse should first calm the infant and increase oxygenation by placing the infant in a knee-chest position and administering 100% oxygen.
A nurse in a pediatric clinic is collecting data from a preschooler during a well-child visit. Which of the following findings should the nurse report to the provider? A. The child is sitting on the exam table and talking to a stuffed animal B. The child's blood pressure is 122/80 mmH C. The child is crying and states, "I don't want any medicine." D. The child's respiratory rate is 22/min
Correct Answer: B. The child's blood pressure is 122/80 mmH. The nurse should identify that this blood pressure measurement indicates significant hypertension, which requires further assessment to confirm. Therefore, the nurse should report this finding to the provider immediately. Incorrect Answers: A. According to Erikson's developmental theory, preschoolers typically develop a sense of initiative during this age period. Play and imagination are important during this stage of development, and the nurse should expect and encourage the child to continue these activities. C. According to Erikson's developmental theory, preschoolers typically develop a sense of initiative during this age and might exhibit assertive behavior. Preschoolers can associate going to a clinic or seeing a nurse with getting medication. The nurse should encourage the child to express feelings during this stage of development.
A nurse is teaching an adolescent client who has juvenile rheumatoid arthritis. Which of the following instructions should the nurse include in the teaching? A. "Apply cold compresses to relieve joint pain. B. "Take opioids routinely." C. "Attend school regularly." D. "Adhere to an arthritis diet."
Correct Answer: C. "Attend school regularly." The nurse should encourage this adolescent who has idiopathic arthritis to attend school. The adolescent should attend school, even on days when she experiences joint pain or stiffness. Incorrect Answers: A. The nurse should instruct a client who has juvenile idiopathic arthritis to apply moist heat to relieve joint pain and stiffness. B. Opioid pain medications are not routinely prescribed for pain associated with juvenile idiopathic arthritis. The nurse should instruct the client to take NSAIDs on a routine schedule to maintain adequate therapeutic levels. D. There is no "arthritis diet" or certain foods for the adolescent to avoid to decrease symptoms of arthritis. However, to avoid excessive weight gain, the nurse should instruct the client to monitor and match her caloric intake to her individual energy needs. D. A preschooler should have a respiratory rate between 20/min and 25/min. However, this rate can vary with activity level. The nurse should count a preschooler's respiratory rate for 1 minute.
