ATI PED FINAL STUDY
A nurse is assessing an infant who has pneumonia. Which of the following findings is the priority for the nurse to report the provider? a. nasal flaring b. WBC count 11,300/mm^3 c. diarrhea d. abdominal distension
A
A nurse is assessing a 6-year-old child at a well-child visit. Which of the following findings requires further assessment by the nurse? A. Presence of sparse, fine pubic hair B. Decreased head circumference compared to full height C. Increased leg length related to height D. Presence of a loose, central incisor
A
A nurse is assessing a 12-month-old male infant's vital signs during a well-child visit. The infant is in the 90th percentile of height. Which of the following findings should the nurse report to the provider? A. Heart rate 175/min B. Respiratory rate 26/min C. Blood pressure 88/40 mm Hg D. Temperature 37.6° C (99.7° F)
A
A nurse is caring for a toddler and is preparing to administer 0.9% sodium chloride 100 mL IV to infuse over 4 hr. The drop factor of the manual IV tubing is 60 gtt/mL. The nurse should set the manual IV infusion to deliver how many gtt/min? (Round the answer to the nearest whole number. Use a leading zero if it applies. Do not use a trailing zero.) ________ gtt
25 gtt
A nurse is assessing an infant who has a ventricular septal defect. Which of the following findings should the nurse expect? a. loud, hard murmur b. dysrhythmias c. weak femoral pulses d. high BP
A
A nurse at a pediatric clinic is assessing a 5-month-old infant during a well-child visit. Which of the following findings should the nurse report to the provider? A. Head lags when pulled from a lying to a sitting position B. Absence of startle and crawl reflexes C. Inability to pick up a rattle after dropping it D. Rolls from back to side
A
A nurse in a health department is caring for an emancipated adolescent who has an STI and is unaccompanied by a guardian. Which of the following actions should the nurse take? a. have the adolescent sign a consent form for treatment b. instruct the adolescent to return with a guardian c. obtain consent from the adolescent's guardian over the phone d. treat the adolescent without a consent form
A
A nurse is caring for a 15 year old client who is married and is scheduled for a surgical procedure. The client asks, "Who should sign my surgical consent?" Which of the following responses should the nurse make? a. "You can sign the consent form because you are married" b. "Your spouse should sign the consent form for you." c. "Your parent should sign the consent form for you" d. "You can appoint a legal guardian to sign the consent form."
A
A nurse is caring for a child who has bacterial endocarditis. The child is scheduled to receive moderate term antibiotic therapy and requires a peripherally inserted central catheter (PICC). Which of the following statements should the nurse include when teaching the child's parent? A. "The PICC line will last several weeks with proper care." B. "The public health nurse will rotate the insertion site every 3 days." C. "You will need to make certain the arm board is in place at all times." D. "Your child will go to the operating room to have the line placed."
A
A nurse is caring for a school age child who has diabetes mellitus and was admitted with a diagnosis of diabetic ketoacidosis. When performing the respiratory assessment, which of the following findings should the nurse expect? a. deep respirations of 32/min b. shallow respirations of 10/min c. paradoxic respirations of 26/min d. periods of apnea lasting for 20 seconds
A
A nurse is caring for a school age child who has peripheral edema. The nurse should identify that which of the following assessments should be performed to confirm peripheral edema? a. palpate the dorsum of the child's feet b. weigh the child daily using the same scale c. assess the child's skin turgor d. observe the child for periorbital swelling
A
A nurse is caring for a school age child who has primary nephrotic syndrome and is taking prednisone. Following 1 week of treatment, which of the following manifestations indicates to the nurse that the medication is effective? a. decreased edema b. increased abdominal girth c. decreased appetite d. increased protein in the urine
A
A nurse is caring for a school-age child who has experienced a tonic-clonic seizure. Which of the following actions should the nurse take during the immediate postictal period? a. place the child in a side-laying position b. delay documentation until the child is fully alert c. give the child a high-carb snack d. administer an oral sedative to the child
A
A nurse is caring for an infant who has respiratory syncytial virus (RSV). Which of the following actions should the nurse implement for a infection control? a. have a designated stethoscope in the infant's room. b. place the infant in a room equipped with negative airflow c. administer palivizumab as prescribed for the infant d. remove gloves after leaving the infant's room
A
A nurse is caring for an infant who is receiving IV fluids for the treatment of Tetralogy of Fallot and begins to have a hypercyanotic spell. Which of the following actions should the nurse take? a. place the infant in a knee-chest position b. administer a dose of meperidine IV c. discontinue administration of IV fluids d. apply oxygen at 2L/min via nasal cannula
A
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? a. avoid palpating the abdomen when bathing the child before surgery b. refrain form auscultating the child's bowel sounds during the postoperative assessment c. encourage the child to play with other children on the unit prior to surgery d. explain to the child that their pain will be managed after the surgery
A
A nurse is creating a plan of care for a school-age child who has heart disease and has developed heart failure. Which of the following interventions should the nurse include in the plan? a. provide small, frequent meals for the child b. schedule time in the play room for the child c. weigh the child weekly d. maintain the child in a supine position
A
A nurse is planning an educational program for school age children and their parents about bicycle safety. Which of the following information should the nurse plan to include? a. the child should be able to stand on the balls of their feet when sitting on the bike b. the child should ride their bike 2 feet to the side of other bike riders c. the child should wear dark colored clothing with a fluorescent stripe when riding at night d. the child should ride the bike facing traffic when it is necessary to tide in the street
A
A nurse is planning developmental activities for a newly admitted 10 year old child who has neutropenia. Which of the following actions should the nurse plan to take? a. provide the child with a book about adventure b. arrange frequent visits from family members and peers c. give the child a large piece puzzle d. use puppets to entertain the child
A
A nurse is planning to collect a specimen from a male infant using a urine collection bag. Which of the following actions should the nurse take? A. Wash and dry the infant's genitalia and perineum thoroughly. B. Apply a small coating of water-soluble lubricant to the skin of the infant's perineal area. C. Avoid placing the scrotum inside the collection bag. D. Wait several hours after positioning the device before checking it.
A
A nurse is providing dietary teaching to the guardian of a school age child who has cystic fibrosis. Which of the following statements should the nurse make? a. "You should offer your child high protein meals and snacks throughout the day." b. "You should decrease your child's dietary fat intake to less than 10% of their caloric intake." c. "You should restrict your child's calorie intake to 1200 per day." d. "you should give your child a multivitamin once weekly."
A
A nurse is providing teaching to the parent of a school age child who has a new prescription for oral nystatin for the treatment of oral candidiasis. Which of the following instructions should the nurse include? a. "Shake the medication prior to administration." b. "Provide the medication through a straw." c. "Rinse the child's mouth with water immediately after giving the medication." d. "Mix the medication with applesauce if the child dislikes the taste."
A
A nurse is providing teaching to the parent of an infant who has diaper dermatitis. The nurse should instruct the parent to apply which of the following to the affected area. a. zinc oxide b. antibiotic ointment c. talcum powder d. antiseptic solution
A
A nurse is providing teaching to the parents of a 4-year-old child about fine motor development. Which of the following tasks should the nurse include in the teaching as an expected finding for this age group? A. Copies a circle B. Cuts foods using a table knife C. Begins writing in cursive D. Prints first and last name clearly
A
A nurse is receiving change of shift report for four children. Which of the following children should the nurse assess first? a. a toddler who has a concussion and an episode of forceful vomiting b. an adolescent who has infective endocarditis and reports having a headache c. an adolescent who was placed into halo traction 1 hr ago and reports pain as 6 on a scale of 0-10 d. a school age child who has acute glomerulonephritis and brown-colored urine
A
A nurse is receiving change-of-shift report for four children. Which of the following children should the nurse see first? a. a school age child who has sickle cell anemia and reports decreased vision in the left eye b. a school age child who has cystic fibrosis and a frequent nonproductive cough c. a preschooler who has asthma and a peak flow meter reading in the green zone d. an adolescent who has meningitis and reports a sensitivity to lights and noise
A
A nurse is reviewing the laboratory report of a 7-year-old child who is receiving chemotherapy. Which of the following laboratory values should the nurse report to the provider? a. hgb 8.5g/dL b. WBC 9500/mm^3 c. prealbumin 18mg/dL d. platelets 300000/mm^3
A
A nurse is reviewing the laboratory report of a school-age child who is experiencing fatigue. Which of the following findings should the nurse recognize as an indication of anemia? a. hematocrit 28% b. hemoglobin 13.5 g/dL c. WBC count 8000mm^3 d. platelets 250000/mm^3
A
A nurse is reviewing the laboratory results of a school age child who is 1 week postoperative following an open fracture repair. Which of the following findings should the nurse identify as an indication of a potential complication? a. erythrocyte sedimentation rate 10mm/hr b. WBC count 6200/mm^3 c. c-reactive protein 1.4mg/L d. RBC count 4.7 million/mm^3
A
A nurse is teaching a group of parents about infectious mononucleosis. Which of the following statements by a parent indicates an understanding the teaching? a. "Mononucleosis is caused by an infection with the Epstein-Barr virus." b. "Mononucleosis is a bacterial infection requiring 14 days of antibiotics." c. "A monospot is a throat culture used to diagnosis mononucleosis." d. "Children who get mononucleosis will need to refrain form sports for 6 months."
A
A nurse is teaching the guardian of a 6 month old infant about car seat use. Which of the following statements by the guardian indicates an understanding of the teaching? a. "I should secure the car seat using lower anchors and tethers instead of the seat belt." b. "I should position the car seat harness 1" above my baby's shoulders." c. "I will make sure that the car seat is placed at a 90 degree angle." d. "I will pad my baby's car seat with a blanket for traveling long distances"
A
A nurse is teaching the guardian of a 6 month old infant about teething. Which of the following statements should the nurse make? a. "your baby might pull at their ears when they are teething." b. "rub your baby's gums with an aspirin to decrease discomfort." c. "place a beaded teething necklace around your baby's neck." d. "Your baby's upper middle teeth will erupt first."
A
A nurse is teaching the parent of a toddler about home safety. Which of the following statements by the parent indicates an understanding of the teaching? A. "I lock my medications in the medicine cabinet." B. "I keep my child's crib mattress at the highest level." C. "I turn pot handles to the side of my stove while cooking." D. "I will give my child syrup of ipecac if she swallows something poisonous."
A
A nurse is teaching the parent of an infant about food allergens. Which of the following foods should the nurse include as being the most common food allergy in children? A. Cow's milk B. Wheat bread C. Corn syrup D. Eggs
A
A nurse providing teaching about promoting sleep with the parent of a 3-year-old toddler. Which of the following information should the nurse include? A. Follow a nightly routine and established bedtime. B. Encourage active play prior to bedtime. C. Let the child remain awake until tired enough to go to sleep. D. Reward the child with a food treat just prior to sleep if the child goes to bed on time.
A
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? a. wheat crackers b. rye bread c. barley soup d. white rice
D
A nurse in an emergency department is caring for a school age child who has epiglottitis. Which of the following actions should the nurse take? a. obtain a throat culture form the child b. monitor the child's oxygen saturation c. put a warm mist humidifier in the child's room d. place the child in the supine position
B
A nurse is planning care for a 10-month-old infant who has suspected failure to thrive (FTT). Which of the following interventions should the nurse include in the plan of care? (Select all that apply.) A. Observe the parents' actions when feeding the child. B. Maintain a detailed record of food and fluid intake. C. Follow the child's cues as to when food and fluids are provided. D. Sit beside the child's high chair when feeding the child. E. Play music videos during scheduled meal times.
A, B
A nurse is an emergency department is assessing a toddler who has Kawasaki disease. Which of the following findings should the nurse expect? (select all that apply.) a. increased temperature b. gingival hyperplasia c. xerophthalmia d. bradycardia e. cervical lymphadenopathy
A, C, E
A nurse is reviewing the dietary choices of an adolescent who has iron deficiency anemia. The nurse should identify that which of the following menu items has the highest amount of nonheme iron? a. 1/2 cup whole milk b. 1 cup orange juice c. 1/2 cup raisins d. 1 cup raw carrots
C
A charge nurse in an emergency department is preparing an in-service for a group of newly licensed nurses about the manifestations of child maltreatment. Which of the following manifestations should the charge nurse include as a potential indication of physical abuse? a. recurrent urinary tract infections b. symmetric burns of the lower extremities c. failure to thrive d. lack of subcutaneous fat
B
A nurse in a pediatric clinic is assessing a toddler at a well-child visit. Which of the following actions should the nurse take? A. Perform the assessment in a head to toe sequence. B. Minimize physical contact with the child initially. C. Explain procedures using medical terminology. D. Stop the assessment if the child becomes uncooperative.
B
A nurse in an emergency department is caring for a school age child who has sustained a minor superficial burn from fireworks on their forearm. Which of the following actions should the nurse take? a. administer the tetanus toxoid vaccine if more than 1 year since the prior dose b. apply an antimicrobial ointment to the affected area c. leave the burn area open to air d. place an ice pack on the affected area
B
A nurse in an emergency department is caring for a school-age child who has appendicitis and rates their pain as 7 on a 0-10 scale. Which of the following actions should the nurse take? a. instill a 500ml tap water enema b. give morphine 0.05mg/kg IV c. administer polyethylene glycol 1g/kg PO d. apply a heating pad to the child's abdomen
B
A nurse in the emergency department is caring for a 2-year-old child who was found by his parents crying and holding a container of toilet bowl cleaner. The child's lips are edematous and inflamed, and he is drooling. Which of the following is the priority action by the nurse? A. Remove the child's contaminated clothing. B. Check the child's respiratory status. C. Administer an antidote to the child. D. Establish IV access for the child.
B
A nurse is assessing a 3 year old toddler at a well-child visit. Which of the following manifestations should the nurse report to the provider? a. BP 90/50 b. RR 45 c weight 14.5 kg (32lbs) d. HR 110
B
A nurse is assessing a 3-year-old child who is 1 day postoperative following a tonsillectomy. Which of the following methods should the nurse use to determine if the child is experiencing pain? A. Ask the parents. B. Use the FACES scale. C. Use the numeric rating scale. D. Check the child's temperature.
B
A nurse is assessing a 6 month old infant during a well child visit. Which of the following findings should the nurse report to the provider? a. presence of a central incisor tooth b. presence of strabismus c. presence of an open anterior fontanel d. presence of external cerumen
B
A nurse is assessing a 9-month-old infant during a well-child visit. Which of the following findings indicates that the infant has a developmental delay? A. Creeps on hands and knees B. Inability to vocalize vowel sounds C. Uses crude pincer grasp D. Stands by holding onto support
B
A nurse is assessing a school age child who has peritonitis. Which of the following findings should the nurse expect? a. hyperactive bowel sounds b. abdominal distention c. bradycardia d. bloody stool
B
A nurse is assessing a school-age child immediately following a perforated appendix repair. Which of the following findings should the nurse expect? a. purulent nasogastric drainage b. absence of peristalsis c. passage of dark stool with mucus d. WBC count 6000mm^3
B
A nurse is assessing a school-age child who has meningitis. Which of the following findings is the priority for the nurse to report to the provider? a. reports a headache as 6 on a 0-10 pain scale b. petechiae on the lower extremities c. nuchal rigidity d. positive Kernig's sign
B
A nurse is caring for a 10 year old child following a head injury. Which of the following findings should the nurse identify as an indication that the child is developing diabetes incipidus? a. urine specific gravity 1.045 b. sodium 155 mEq/L c. blood glucose 45 mg/dL d. urine output 35 mL/hr
B
A nurse is caring for a school-age child who is receiving a blood transfusion. Which of the following manifestations should alert the nurse to a possible hemolytic transfusion reaction? a. laryngeal edema b. flank pain c. distended neck veins d. muscular weakness
B
A nurse is caring for a school-age child who is receiving cefazolin via intermittent IV bolus. The child suddenly develops diffuse flushing of the skin and angioedema. After discontinuing the medication infusion, which of the following medications should the nurse administer first? a. prednisone b. epinephrine c. diphenhydramine d. albuterol
B
A nurse is caring for a toddler who has acute otitis media and a temperature of 40 degree C (104 degrees F). After administering acetaminophen, which of the following actions should the nurse plan to take to reduce the toddler's temperature? a. apply a cooling blanket to the toddler b. dress the toddler in minimal clothing c. give the toddler a tepid bath d. administer diphenhydramine to the toddler
B
A nurse is caring for an 18-year-old adolescent who is up-to-date on immunizations and is planning to attend college. The nurse should inform the client that he should receive which of the following immunizations prior to moving into a campus dormitory? A. Pneumococcal polysaccharide B. Meningococcal polysaccharide C. Rotavirus D. Herpes zoster
B
A nurse is caring for an adolescent who received a kidney transplant. Which of the following findings should the nurse identify as an indication the adolescent is rejecting the kidney? a. negative leukocyte esterase b. serum creatinine 3.0 mg/dL c. negative urine protein d. urine output 40ml/hr
B
A nurse is developing a plan of care for a school-age child who underwent a surgical procedure that resulted in a temporary loss of vision. Which of the following interventions should the nurse include in the plan of care? A. Assign an assistive personnel to feed the child. B. Explain sounds the child is hearing. C. Have the child use a cane when ambulating. D. Rotate nurses caring for the child.
B
A nurse is monitoring the oxygen saturation level of an infant using pulse oximetry. The nurse should secure the sensor to which of the following areas on the infant? a. wrist b. great toe c. index finger d. heel
B
A nurse is performing a physical assessment on a 6-month-old infant. Which of the following reflexes should the nurse expect to find? A. Stepping B. Babinski C. Extrusion D. Moro
B
A nurse is planning an educational program to teach parents about protecting their children from sunburns. Which of the following instructions should the nurse plan to include? a. "allow your child to play outside during the hours between 10:00am and 2:00pm." b. "choose a waterproof sunscreen with a minimum SPF of 15." c. "dress you child in loose weave polyester fabric prior to sun exposure." d. "reapply sunscreen every 4 hours."
B
A nurse is preparing an adolescent for a lumbar puncture. Which of the following actions should the nurse take? a. place a cardiac monitor on the adolescent prior to the procedure b. apply topical analgesic cream to the site 1hr prior to the procedure c. keep the adolescent in a semi-fowler's position for 4hrs following the procedure d. restrict fluids for 2hrs following procedure
B
A nurse is preparing to administer a liquid medication to an infant. Which of the following actions should the nurse take? A. Administer the medication while the infant is supine. B. Give the medication at the side of the infant's mouth. C. Add the medication to a full bottle of the infant's formula. D. Administer the medication slowly while holding the nares closed.
B
A nurse is providing discharge teaching to the guardians of a toddler who had a lower leg cast applied 24 hours ago. The nurse should instruct the guardians to report which of the following findings to the provider? a. capillary refill time less than 2 seconds b. restricted ability to move the toes c. swelling of the casted foot when the leg is dependent d. pedal pulse +3 bilateral
B
A nurse is providing discharge teaching to the parent of a child who is 1 week postop following a cleft palate repair. For which of the following members of the interprofessional team should the nurse initiate a referral? a. occupational therapist b. speech therapist c. respiratory therapist d. physical therapist
B
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? a. "I should buy plastic shoes to wear at the swimming pool." b. "I should wear sandals as much as possible." c. "I should place the permethrin cream between my toes twice daily." d. "I should seal my nonwashable shoes in plastic bags for a couple of weeks."
B
A nurse is providing teaching to the family of a school-age child who has juvenile idiopathic arthrisis. Which of the following instructions should the nurse include in the teaching? a. "limit movement of the child's large joints" b. "encourage the child to perform independent self-care." c. "provide the child with a soft mattress for sleeping." d. "schedule a 2 hour daily nap for the child in the afternoon."
B
A nurse is providing teaching to the parents of a preschooler who has heart failure and a new prescription for digoxin twice daily. Which of the following instructions should the nurse include in the teaching? a. "Use a kitchen teaspoon to measure the medication." b. "Brush the child's teeth after giving the medication." c. "double the next dose if the child misses a dose." d. "repeat the dose if the child vomits."
B
A nurse is reviewing the laboratory report of an infant who is receiving treatment for severe dehydration. The nurse should identify that which of the following laboratory values indicates effectiveness of the current treatment? a. potassium 2.9 mEq/l b. sodium 140 mEq/L c. urine specific gravity 1.035 d. BUN 25 mg/dL
B
A nurse is teaching a school age child who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the child indicates an understanding of the teaching? a. "I will puncture the pad of my finger when I am testing my blood glucose." b. "I will give myself a shot of regular insulin 30 minutes before I eat breakfast." c. "I will eat a snack of 5 grams of carbohydrates if my blood glucose is low." d. "I will decrease the amount of fluids I drink when I am sick."
B
A nurse is teaching the parents of a school-age child who has a new diagnosis of osteomyelitis of the tibia. Which of the following statements by a parent indicates an understanding of the teaching? a. "My child will have a cast until healing is complete." b. "My child will receive antibiotics for several weeks." c. "My child can return to playing sports once they have been discharged." d. "My child needs to be in contact isolation."
B
A nurse is teaching the parents of a toddler who has a cognitive impairment about toilet training. Which of the following instructions should the nurse include in the teaching a. "scold your child when they have toileting accident." b. "award your child with a sticker when they sit on the potty chair." c. "play your child's favorite song while teaching them to use the potty chair." d. "teach multiple steps of the skill at the same time."
B
A nurse on a pediatric unit is admitting a 4-year-old child. Which of the following toys should the nurse plan to provide for the child to engage in independent play? A. Brightly colored mobile B. Plastic stethoscope C. Small piece jigsaw puzzle D. A book of short stories
B
A nurse is admitting an infant who has intussesception. Which of the following findings should the nurse expect? (select all that apply) a. steatorrhea b. vomiting c. lethargy d. constipation e. weight gain
B, C
A nurse is caring for a toddler who has spastic (pyramidal) cerebral palsy. Which of the following findings should the nurse expect? (Select all the apply) a. negative Babinski reflex b. ankle clonus c. exaggerated stretch reflexes d. uncontrollable movements of the face e. contractures
B, C, E
A charge nurse is preparing to make a room assignment for a newly admitted school age child. Which of the following considerations is the nurse's priority? a. length of stay b. treatment schedule c. disease process d. self-care ability
C
A nurse in a provider's office is caring for a school age child who has varicella. The parent asks the nurse when their child will no longer be contagious. Which of the following responses should the nurse make? a. "When your child no longer has an increased temperature." b. "Three days after you first noticed the rash appear on your child." c. "When you child's lesions are crusted, usually 6 days after they appear." d. "Two to three weeks, when your child's lesions completely disappear."
C
A nurse in an emergency department is assessing a 3 month old infant who has rotavirus and is experiencing acute vomiting and diarrhea. Which of the following manifestations should the nurse identify as an indication that the infant has moderate to severe dehydration? a. HR 124 b. increased tear production c. sunken anterior fontanel d. capillary refill 2 seconds
C
A nurse in an emergency department is caring for a toddler who has partial-thickness burns on their right arm. Which of the following actions should the nurse take? a. insert a nasogastric tube b. initiate prophylactic antibiotic use c. cleanse the affected area with mild soap and water d. apply a topical corticosteroid to the affected area
C
A nurse in an urgent care clinic is assessing an adolescent who has an upper respiratory tract infection. Which of the following findings should the nurse identify as a manifestation of pertussis? a. inflamed throat with exudate b. purulent eye drainage c. dry, hacking cough d. kolpik spots on a buccal mucosa
C
A nurse in the emergency department is caring for a 12-year-old child who has ingested bleach. Which of the following statements by the nurse indicates an understanding of this ingestion? A. "The absence of oral burns excludes the possibility of esophageal burns." B. "Treatment focuses on neutralization of the chemical." C. "Injury by a corrosive liquid is more extensive than by a corrosive solid." D. "Immediate administration of activated charcoal is warranted."
C
A nurse is assessing a 30-month-old toddler during a well-child visit. Which of the following findings requires further assessment by the nurse? A. Primary dentition is complete B. Unable to hop on one foot C. Birth weight is tripled D. Able to state first and last name
C
A nurse is assessing a 4 year old child at a well-child visit. Which of the following developmental milestones should the nurse expect to observe? a. identifies right from left hand b. uses a utensil to spread butter c. cuts an outlined shape using scissors d. draws a stick figure with seven body parts
C
A nurse is assessing a 6-month-old infant at a well-child visit. Which of the following findings indicates the need for further assessment? A. Grabs feet and pulls them to her mouth B. Posterior fontanel is closed C. Legs remain crossed and extended when supine D. Birth weight has doubled
C
A nurse is assessing a 7-year-old child's psychosocial development. Which of the following findings should the nurse recognize as requiring further evaluation? A. The child prefers playmates of the same sex. B. The child is competitive when playing board games. C. The child complains daily about going to school. D. The child enjoys spending time alone.
C
A nurse is assessing a school age child who has an infratentorial brain tumor. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure? a. hypotension b. reports insomnia c. difficulty concentrating d. tachycardia
C
A nurse is assessing an 8 year old child who has early indication of shock. After establishing an airway and stabilizing the child's respirations, which of the following actions should the nurse take next? a. insert an indwelling urinary catheter b. measure weight and height c. initiate IV access d. maintain ECG monitoring
C
A nurse is assessing an adolescent who received a sodium polystyrene sulfonate enema. Which of the following findings indicates effectiveness of the medication? a. reports an absence of nausea and vomiting b. reports experiencing an onset of loose stools within 15 minutes of administration c. serum potassium level 4.1 mEq/L d. blood pressure 86/52 mm Hg
C
A nurse is assessing the vital signs of a 10 year old child following a burn injury. The nurse should identify that which of the following findings is an indication of early septic shock? a. blood pressure 130/90 mm Hg b. HR 60/min c. Temp 39.1 Degrees C (102.4 Degrees F) d. urinary output 100ml/hr
C
A nurse is caring for a 1 month old infant who is breastfeeding and requires a heel stick. Which of the following actions should the nurse take to minimize that infant's pain? a. Use a manual lancet to obtain the heel blood sample b. apply an ice pack to the infant's heel prior to obtaining the sample c. allow the mother to breastfeed while the sample is being obtained d. apply a topical lidocaine cream prior to obtaining the sample
C
A nurse is caring for a 15 year old client following a head injury. Which of the following should the nurse identify as an indication that the child is developing syndrome of inappropriate antidiuretic hormone secretion (SIADH)? a. sodium 148 mEq/L b. urine specific gravity 1.020 c. mental confusion d. weak peripheral pulses
C
A nurse is caring for a 15-month-old toddler who requires droplet precautions. Which of the following actions should the nurse take? A. Have the toddler wear a disposable gown when in the unit's playroom. B. Wear sterile gloves when changing the toddler's diapers. C. Wear a mask when assisting the toddler with meals. D. Ask visitors to wear an N-95 mask when entering the room.
C
A nurse is caring for a newly admitted school age child who has hypopituitarism. Which of the following medications should the nurse expect the provider to prescribe? a. Desmopressin b. Luteinizing hormone-releasing hormone c. Recombinant growth hormone d. Levothyroxine
C
A nurse is caring for a preschooler who is scheduled for hydrotherapy treatment for wound debridement following a burn injury. Which of the following actions should the nurse take prior to the procedure? a. apply topical antimicrobial ointment to the child's wound. b. place a mesh gauze dressing over the child's wound c. administer an analgesic to the child d. initiate prophylactic antibiotic therapy for the child
C
A nurse is caring for a school age child who is receiving chemotherapy and is severely immunocompromised. Which of the following actions should the nurse take? a. use surgical asepsis when providing routine care for the child b. administer the measles, mumps, and rubella (MMR) vaccine to the child c. screen the child's visitors for indications of infection d. infuse packed RBCs
C
A nurse is caring for a school-age child who is in Buck's traction following a leg fracture 24 hours ago. Which of the following actions should the nurse take? a. change the child's position every 2hrs b. clean the peripheral pin sites with chlorhexidine solution every 4 days c. assess peripheral pulses once every 4 hours d. ensure that the head of the bed is elevated to a 90 degree angle
C
A nurse is observing a mother who is playing peek-a-boo with her 8-month-old child. The mother asks if this game has any developmental significance. The nurse should inform the mother that peek-a-boo helps develop which of the following concepts in the child? A. Hand-eye coordination B. Sense of trust C. Object permanence D. Egocentrism
C
A nurse is preparing to administer an immunization to a 4 year old child. Which of the following actions should the nurse plan to take? a. place the child in a prone position for the immunization b. request that the child's caregiver leave the room during the immunization c. administer the immunization using a 24 gauge needle d. inject the immunization slowly after aspiration for 3 seconds
C
A nurse is preparing to administer recommended immunizations to a 2-month-old infant. Which of the following immunizations should the nurse plan to administer? A. Human papillomavirus (HPV) and hepatitis A B. Measles, mumps, rubella (MMR) and tetanus, diphtheria, and acellular pertussis (TDaP) C. Haemophilus influenzae type B (Hib) and inactivated polio virus (IPV) D. Varicella (VAR) and live attenuated influenza vaccine (LAIV)
C
A nurse is preparing to collect a sample form a toddler for a sickle-turbidity test. Which of the following actions should the nurse plant to take? a. obtain a sputum specimen b. perform an Allen test c. perform a finger stick d. obtain a stool specimen
C
A nurse is providing anticipatory guidance about accidental ingestion of a toxic substance to the parents of a toddler. The nurse should instruct the parents to take which of the following actions first if the child ingests a hazardous substance? A. Give the toddler milk. B. Go to an emergency department. C. Call the poison control center. D. Induce vomiting.
C
A nurse is providing discharge teaching to the guardian of a school age child who has undergone a tonsillectomy. Which of the following statements by the guardian indicates an understanding the teaching? a. "my child can resume usual activities since this year just an outpatient surgery." b. "my child will be able to drink the chocolate milkshake I promised to get for them tonight." c. "I will notify the doctor if I notice that my child is swallowing frequently." d. "I will have my child gargle with warm salt water to relieve their sore throat."
C
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? a. "you should give your child their salmeterol inhaler every 4 hours when they are having an acute episode of wheezing." b. "you should monitor your child's weight weekly while they are receiving inhaled corticosteroids therapy." c. "pulmonary function tests will be performed every 12-24 months to evaluate how your child is responding to therapy." d. "when using the peak expiratory flow meter, record your child's average of three readings."
C
A nurse is providing discharge teaching to the parent of an 18 month old toddler who has dehydration due to acute diarrhea. Which of the following statements by the parent indicates an understanding of the teaching? a. "I will offer my child small amounts of fruit juice frequently." b. "I will avoid giving my child solid foods until the diarrhea has stopped." c. "I will monitor my child's number of wet diapers." d. "I will give my child polyethylene glycol daily for 7 days."
C
A nurse is providing education to the parent of a toddler who is about to receive her first dose of the MMR (measles, mumps and rubella) immunization. Which of the following statements by the parent indicates an understanding of the teaching? A. "I am not going to let my child play with other children for 2 days." B. "I will need to return in 2 weeks for my child to receive the varicella immunization." C. "I can give my child acetaminophen for discomfort associated with the immunization." D. "My child might have some discharge from the injection site."
C
A nurse is reviewing the lumbar puncture results of a school-age child who is suspected of having bacterial meningitis. Which of the following findings should the nurse identify as an indication of bacterial meningitis? a. decreased cerebrospinal fluid pressure b. decreased WBC count c. increased protein concentration d. increased glucose level
C
A nurse is teaching a school age child and their parent about postoperative care following cardiac catheterization. Which of the following instructions should the nurse include? a. "Stay home from school for 1 week following the procedure." b. "follow a diet that is low in fiber for 1 week." c. "wait 3 days before taking a tub bath." d. "apply a pressure dressing to the site for 3 days."
C
A nurse on a pediatric unit is reviewing the health record of a client who is demonstrating increasing levels of stress after admission. The nurse should identify which of the following findings as a risk factor for a stress-related reaction to hospitalization? A. Age 10 B. First hospitalization C. Male gender D. Calm, quiet demeanor
C
A school nurse is assessing an adolescent who has multiple burns in various stages of healing. Which of the following behaviors should the nurse identify as a possible indication of physical abuse? a. expresses a reluctance to leave home b. provides a detailed description of how the burns occurred c. denies discomfort during assessment of injuries d. describes strong relationship with peers
C
A school nurse is caring for a child following a tonic-clonic seizure. Which of the following actions should the nurse take first? a. check the child for a head injury b. observe for oral bleeding c. check the child's respiratory rate d. observe for extremity weakness
C
A nurse is caring for a preschooler who has been receiving IV fluids via a peripheral IV catheter. When preparing to discontinue the IV fluids and catheter, which of the following actions should the nurse plan to take? (place in order of performance) a. remove the tape securing the catheter b. occlude the IV tubing c. Turn off the IV pump d. apply pressure over the catheter insertion site
C, B, A, D
A nurse is teaching the parent of an infant about home safety. Which of the following information should the nurse include? (Select all that apply.) A. Use a wheeled infant walker. B. Place soft pillows around the edge of the infant's crib. C. Position the car seat so it is rear-facing. D. Secure a safety gate at the top and bottom of the stairs. E. Maintain the water heater temperature at 49° C (120° F).
C, D, E
A community health nurse is assessing an 18 month old toddler in a community day care. Which of the following findings should a nurse identify as a potential indication of physical neglect? a. resists having an axillary temperature taken b. exhibits withdrawal behaviors when their parent leaves c. has multiple bruises on their knees d. poor personal hygiene
D
A hospice nurse is caring for a preschooler who has a terminal illness. One of the preschooler's parents tells the nurse that they cannot cope anymore and are thinking about moving out of the house. Which of the following statements should the nurse make? a. "it is important that you provide emotional support for your family at this time." b. "You have to do what you feel is best. Everything will turn out fine." c. "I know how you feel. This is an extremely stressful time for your family." d. "Let's talk about some of the ways you have handled previous stressors in your life."
D
A nurse in an emergency department is caring for a 4-year-old child who has burns to the neck and face following a house fire. Which of the following actions should the nurse take first? A. Cover the child's wounds with a clean, dry cloth. B. Establish IV access for the child with a large-bore catheter. C. Provide reassurance to the child's parents. D. Determine the child's breathing pattern.
D
A nurse in an emergency department is caring for a school age child who is experiencing an anaphylactic reaction. Which of the following is the priority action by the nurse? a. elevate the head of the child's bed b. insert a large bore IV catheter for a child c. determine the allergen that caused the child's reaction d. administer epinephrine IM to the child
D
A nurse in an emergency department is caring for an 8-year old who is up-to-date with current immunization recommendations and has a deep puncture injury. Which of the following should the nurse anticipate administering? A. Diphtheria, tetanus, and acellular pertussis (DTaP) vaccine B. A single injection of tetanus immune globulin (TIG) mixed with the pediatric tetanus booster (DT) C. Tetanus, diphtheria, and acellular pertussis (Tdap) vaccine D. Adult tetanus booster (Td)
D
A nurse in an emergency department is performing a physical assessment on a 2 week old male newborn. Which of the following findings is priority for the nurse to report to the provider? a. excoriated scrotal area b. multiple capillary hemangiomas c. depressed posterior fontanel d. substernal retractions
D
A nurse is admitting a school-age child who has pertussis. Which of the following actions should the nurse take? a. place the child in a room with a positive pressure airflow b. place the child in a room with a negative pressure airflow c. initiate contact precautions for the child d. initiate droplet precautions for the child
D
A nurse is assessing a toddler who has gastroenteritis and is exhibiting manifestations of dehydration. Which of the following findings is the nurses priority? a. skin breakdown b. hypotension c. hyperpyrexia d. tachypnea
D
A nurse is assisting a provider during a femoral venipuncture on a toddler. The nurse should place the child in which of the following positions? A. Side-lying B. Semi-recumbent C. Flexed sitting D. Supine
D
A nurse is caring for a 2-year-old child who has cystic fibrosis. The nurse is planning to take the child to the playroom. Which of the following activities would be appropriate for the child? A. Cutting figures from colored paper B. Drawing stick figures using crayons C. Riding a tricycle D. Building towers of blocks
D
A nurse is caring for a preschooler who has congestive heart failure. The nurse observes wide QRS complexes and peaked T waves on the cardiac monitor. Which of the following prescriptions should the nurse clarify with the provider? a. furosemide b. captopril c. regular insulin d. potassium chloride
D
A nurse is caring for a preschooler whose father 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 their father will return? a. "your daddy will back at 7pm." b. "Your daddy will be back after he takes care of your brother." c. "Your daddy will be back in the morning" d. "Your daddy will be back after you eat."
D
A nurse is caring for a toddler who is experiencing acute diarrhea and has moderate dehydration. Which of the following nutritional items should the nurse offer to the toddler? a. apple juice b. peanut butter c. chicken broth d. oral rehydration solution
D
A nurse is caring for an adolescent who is receiving pain medication via a PCA pump. When the nurse assesses the client's pain at 0800, the client describes the pain as a 3 on a scale of 1 to 10. At 1000, the client describes the pain as a 5. The nurse discovers the client has not pushed the button to deliver medication in the past 2 hr. Which of the following actions should the nurse take? A. Ask the provider to discontinue the PCA so the nurse can administer PRN pain medication. B. Suggest the client's parent push the button for the client if the parent thinks the adolescent is having pain. C. Reevaluate the client in 1 hr since a pain level of 5 is acceptable on a scale of 1 to 10. D. Reinforce teaching with the client about how to push the button to deliver the medication.
D
A nurse is creating a plan of care for a child who has varicella. which of the following interventions should the nurse include? a. maintain the child's room temperature at 80 degrees F b. prepare the child for a lumbar puncture c. administer aspirin to the child for a temperature greater than 38.3 degrees C (101 degrees F) d. initiate airborne precautions for the child
D
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? a. until the adolescent is afebrile b. for 7 days following admission to the facility c. until the adolescent has a negative blood culture d. for 24 hrs following initiation of antimicrobial therapy
D
A nurse is creating a plan of care for an infant who has an epidural hematoma form a head injury. Which of the following interventions should the nurse include in the plan? a. position the infant side-lying with their head at a )-5 degree angle b. perform a neurological assessment Q4hrs c. suction the infant's nares to remove secretions d. implement seizure precautions for the infant
D
A nurse is discussing organ donation with the parents of a school age child who has sustained brain death due to a bicycle crash. Which of the following actions should the nurse take first? a. inform the parents that written consent is required prior to organ donation b. provide written information to the parents about organ donation c. ask the provider to explain misconceptions of organ donation to the parents. d. explore the parents feelings and wishes regarding organ donation
D
A nurse is interviewing the parent of an 18 month old toddler during a well child visit. The nurse should identify that which of the following findings indicates a need to assess the toddler for hearing loss? a. the toddler has a vocabulary of 25 words b. The toddler developed a mild rash following a recent varicella immunization c. the toddler's Moro reflex is absent d. the toddler received tobramycin during a hospitalization 2 weeks ago
D
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?a. an 18 month old toddler who has unintelligible speech b. a 3 month old infant who has exaggerated startle response c. a 4 year old preschooler who prefers playing with others rather than alone d. an 8 month old infant who is not yet making babbling sounds
D
A nurse is planning care for a newly admitted school age child who has generalized seizure disorder. Which of the following interventions should the nurse plan to include? a. ensure that a padded tongue blade is at the child's bedside b. allow the child to play video games on a tablet computer c. allow the child to take a tub bath independently d. ensure the oxygen source is functioning in the child's room
D
A nurse is planning care for a school age child who has a tunneled central venous access device. Which of the following interventions should the nurse include in the plan? a. use sterile scissors to remove the dressing from the site b. irrigate each lumen weekly with 10 ml of 0.9% sodium chloride solution when not in use c. access the site suing a noncoring angle needle d. use a semipermeable transparent depressing to cover the site
D
A nurse is planning care for a school-age child who is in the oliguric phase of acute kidney injury (AKI) and has a sodium level of 129 meq/L. Which of the following interventions should the nurse include in the plan? a. administer ibuprofen to the child for a temperature greater than 38 degrees C (100.4 degrees F) b. assess the child's blood pressure every 8hr c. weigh the child weekly at a various times of the day d. initiate seizure precautions for the child
D
A nurse is planning care for a toddler who has a serum lead level of 4 mcg/dL. Which of the following actions should the nurse plan to take? a. instruct the parents to decrease the calcium in their toddler's diet b. prepare the toddler for chelation therapy c. refer the family to child protective services d. schedule the toddler for a yearly rescreening
D
A nurse is planning care to address nutritional needs for a preschooler who has cystic fibrosis. Which of the following interventions should the nurse include in the plan? a. administer pancreatic enzymes 2 hours after meals b. discontinue the use of pancreatic enzymes if steatorrhea develops c. limit fluid intake to 750 mL per day d. increase fat content in the child's diet to 40% of total calories.
D
A nurse is planning to implement relaxation strategies with a young child prior to a painful procedure. Which of the following actions should the nurse take? A. Ask the child to hold his breath and then blow it out slowly. B. Ask the child to describe a pleasurable event. C. Bounce the child gently while holding him upright. D. Rock the child in long rhythmic movements.
D
A nurse is providing anticipatory guidance to the parent of a toddler. Which of the following expected behavior characteristics of toddlers should the nurse include? a. controls impulsive feelings b. understands right from wrong c. easily separates from parents for long periods of time d. expresses likes and dislikes
D
A nurse is providing discharge teaching to he parents of a 3 month old infant following a cheiloplasty. Which of the following instructions should the nurse include? a. "clean your baby's sutures daily with a mixture of chlorhexidine and water." b. "expect your baby to swallow more than usual over the next few days." c. "inspect your baby's tongue for white patches using a tongue depressor every 8 hours." d. "apply a thin layer of antibiotic ointment on your baby's suture line daily for the next 3 days."
D
A nurse is providing discharge teaching to the parents of a 6 month old infant who is postoperative following hypospadias repair with a stent placement. Which of the following instructions should the nurse include in the teaching? a. "you may bathe your infant in an infant bathtub when you go home." b. "apply hydrocortisone cream to your infant's penis daily." c. "you should clamp your infant's stent twice daily." d. "allow the stent to drain directly into your infant's diaper."
D
A nurse is providing teaching about play activities for social development to the parents of a preschooler. Which of the following play activities should the nurse recommend for the child? a. playing pat-a-cake b. using a push-pull toy c. creating a scrapbook d. playing dress-up
D
A nurse is teaching a parent of a 12-month old child about development during the toddler years. Which of the following statements should the nurse include? A. "Your child should be referring to himself using the appropriate pronoun by 18 months of age." B. "A toddler's interest in looking at pictures occurs at 20 months of age." C. "A toddler should have daytime control of his bowel and bladder by 24 months of age." D. "Your child should be able to scribble spontaneously using a crayon at the age of 15 months."
D
A nurse is teaching the parent of a 12-month-old infant about nutrition. Which of the following statements by the parent indicates a need for further teaching? A. "I can give my baby 4 ounces of juice to drink each day." B. "I will offer my baby dry cereal and chilled banana slices as snacks." C. "I am introducing my baby to the same foods the family eats." D. "My infant drinks at least 2 quarts of skim milk each day."
D
A nurse is teaching the parent of a preschooler about ways to prevent acute asthma attacks. Which of the following statements by the parent indicates an understanding of the teaching? a. "I will use a humidifier in my child's room at night." b. "I will give my child a cough suppressant Q6hrs if he has a cough." c. "I should avoid using a wet mop on my floors when I am cleaning." d. "I house keep my child indoors when I mow the yard."
D
A nurse is teaching the parent of an infant about ways to prevent sudden infant death syndrome (SIDS). Which of the following instructions should the nurse include? a. "Place the infant in a prone position to sleep." b. "Allow the infant to sleep on a large pillow." c. "Use a soft mattress in the infant's crib." d. "Give the infant a pacifier at bedtime."
D
A nurse is teaching the parent of an infant who has Pavlik harness for the treatment of developmental dysplasia of the hip. The nurse should identify that which of the following statements by the parent indicates an understanding of the teaching? a. "I should remove the harness at night to allow my infant to stretch her legs." b. "I will need to adjust the straps on the harness once a week." c. "I should apply baby powder to my infant's skin twice daily." d. "I will place my infant's diaper under the harness straps."
D
A school nurse is assessing an adolescent who has scoliosis. Which of the following findings should the nurse expect? a. increase anterior convexity of the lumbar spine b. increased curvature of the thoracic spine c. lateral flexion of the neck d. a unilateral rib hump
D
A school nurse is providing an in service for faculty about improving education for students who have ADHD. Which of the following statements by a faculty member indicates an understanding of the teaching? a. "I will plan to increase the amount of homework I assign to students who have ADHD." b. "I will give students who have ADHD the same amount of time as other students to complete tests." c. "I will allow students who have ADHD one rest break throughout the day." d. "I will teach challenging academic subjects to students who have ADHD in the morning."
D
A nurse in a pediatric clinic is caring for a 3-year-old child who has a blood lead level of 3 mcg/dL. When teaching the toddler's parent about the correlation of nutrition with lead poisoning, which of the following information is appropriate for the nurse to include in the teaching? A. Decrease the child's vitamin C intake until the blood lead level decreases to zero. B. Administer a folic acid supplement to the child each day. C. Give pancreatic enzymes to the child with meals and snacks. D. Ensure the child's dietary intake of calcium and iron is adequate.
D, A
A nurse is caring for a preschool-age child who is dying. Which of the following findings is an age-appropriate reaction to death by the child? (Select all that apply.) A. The child views death as similar to sleep. B. The child is interested in what happens to his body after death. C. The child recognizes that death is permanent. D. The child believes his thoughts can cause death. E. The child thinks death is a punishment.
D, E
A nurse is assessing the pain level of a 3 year old toddler. Which of the following assessment scales should the nurse use? a. FACES b. Numeric c. CRIES d. Visual analog
a