Chapter 22
A 1-month-old infant is admitted to the hospital. The infants mother is 17 years old and single and lives with her parents. Who signs the informed consent for the 1-month-old infant? a. The infants mother b. The maternal grandparents of the infant c. The paternal grandparents of the infant d. Both the infants mother and the maternal grandparents
A
A 10-year-old child requires daily medications for a chronic illness. Her mother tells the nurse that the child continually forgets to take the medicine unless reminded. What nursing action is most appropriate to promote adherence to the medication regimen? a. Establish a contract with her, including rewards. b. Suggest time-outs when she forgets her medicine. c. Discuss with her mother the damaging effects of her rescuing the child. d. Ask the child to bring her medicine containers to each appointment so they can be counted.
A
A 16-year-old girl comes to the pediatric clinic for information on birth control. The nurse knows that before this young woman can be examined, consent must be obtained from which source? a. Herself b. Her mother c. Court order d. Legal guardian
A
A 2-year-old child has to receive Rocephin IM injections every 12 hours. What nursing intervention should be implemented for the child? a. Hold the child while rocking in a chair after each injection. b. Prepare the child several hours before the injection is given. c. Allow the child to watch a younger child receive an injection. d. Encourage the child to draw a picture of the pain experienced when an injection is given.
A
A 4-year-old girl is admitted to outpatient surgery for removal of a cyst on her back. Her mother puts the hospital gown on her, but the child is crying because she wants to leave on her underpants. What is the most appropriate nursing action at this time?? a. Allow her to wear her underpants. b. Discuss with her mother why this is important to the child. c. Ask her mother to explain to her why she cannot wear them. d. Explain in a kind, matter-of-fact manner that this is hospital policy.
A
A 6-year-old boy is hospitalized for intravenous antibiotic therapy. He eats very little on his regular diet trays. He tells the nurse that all he wants to eat is pizza, tacos, and ice cream. What nursing action is the most appropriate? a. Request these favorite foods for him. b. Identify healthier food choices that he likes. c. Explain that he needs fruits and vegetables. d. Reward him with ice cream at the end of every meal that he eats.
A
A child, age 7 years, has a fever associated with a viral illness. She is being cared for at home. What is the principal reason for treating fever in this child? a. Relief of discomfort b. Reassurance that illness is temporary c. Prevention of secondary bacterial infection d. Avoidance of life-threatening complications
A
The nurse is administering an IM injection into a vastus lateralis muscle of a 6-month-old infant. What should the length of the needle and amount to be given be? a. 5/8 to 1 inch; 0.5 to 1.0 ml b. 1 inch to 1 1/2 inch; 1.0 to 2.0 ml c. 1 inch to 1 1/2 inch; 0.5 to 1.0 ml d. 5/8 to 1 inch; 0.75 to 2 ml ANS: A The length of a needle for an infant should be 5/8 to 1 inch, and the amount of solution should not exceed 1 ml.
A
The nurse needs to take the blood pressure of a preschool boy for the first time. What action would be best in gaining his cooperation? a. Tell him that this procedure will help him get well faster. b. Take his blood pressure when a parent is there to comfort him. c. Explain to him how the blood flows through the arm and why the blood pressure is important. d. Permit him to handle the equipment and see the cuff inflate and deflate before putting the cuff in place.
D
What is a priority intervention for an infant with a temporary colostomy for Hirschsprung disease? a. Teaching how to irrigate the colostomy b. Protecting the skin around the colostomy c. Discussing the implications of a colostomy during puberty d. Using simple, straightforward language to prepare the child
B
What is an advantage of the ventrogluteal muscle as an injection site in young children? a. Easily accessible from many directions b. Free of significant nerves and vascular structures c. Can be used until child reaches a weight of 9 kg (20 lb) d. Increased subcutaneous fat, which provides sustained drug absorption
B
A bone marrow biopsy will be performed on a 7-year-old girl. She wants her mother to hold her during the procedure. How should the nurse respond? a. Holding your child is unsafe. b. Holding may help your child relax. c. Hospital policy prohibits this interaction. d. Holding your child is unnecessary given the childs age.
B
A child who has cystic fibrosis is admitted to the pediatric unit with methicillin-resistant Staphylococcus aureus (MRSA) infection. The nurse recognizes that in addition to a private room, the child is placed on what precautions? a. Droplet b. Contact c. Airborne d. Standard
B
A laboratory technician is performing a blood draw on a toddler. The toddler is holding still but crying loudly. The nurse should take which action? a. Have the lab technician stop the procedure until the child stops crying. b. Do nothing. Its Okay for a child to cry during a painful procedure. c. Tell the child to stop crying; its only a small prick. d. Tell the child to stop crying because the procedure is almost over.
B
A nurse must do a venipuncture on a 6-year-old child. What consideration is important in providing atraumatic care? a. Use an 18-gauge needle if possible. b. Show the child the equipment to be used before the procedure. c. If not successful after four attempts, have another nurse try. d. Restrain the child completely.
B
A toddler is being sent to the operating room for surgery at 9 AM. As the nurse prepares the child, what is the priority intervention? a. Administering preoperative antibiotic b. Verifying that the child and procedure are correct c. Ensuring that the toddler has been NPO since midnight d. Informing the parents where they can wait during the procedure
B
An 11-month-old hospitalized boy is restrained because he is receiving intravenous (IV) fluids. His grandmother has come to stay with him for the afternoon and asks the nurse if the restraints can be removed. What nurses response is best? a. Restraints need to be kept on all the time. b. That is fine as long as you are with him. c. That is fine if we have his parents consent. d. The restraints can be off only when the nursing staff is present.
B
At which age should a nurse keep teaching time short (5 minutes)? a. Infant b. Toddler c. Preschool d. School age
B
Guidelines for intramuscular administration of medication in school-age children include what standard? a. Inject medication as rapidly as possible. b. Insert needle quickly, using a dartlike motion. c. Have the child stand if at all possible and if the child is cooperative. d. Penetrate the skin immediately after cleansing the site while the skin is moist.
B
The nurse gives an injection in a patients room. How should the nurse dispose of the needle? a. Remove the needle from the syringe and dispose of it in a proper container. b. Dispose of the syringe and needle in a rigid, puncture-resistant container in the patients room. c. Close the safety cover on the needle and return it to the medication preparation area for proper disposal. d. Place the syringe and needle in a rigid, puncture-resistant container in an area outside of the patients room.
B
The nurse has just collected blood by venipuncture in the antecubital fossa. What should the nurse do next? a. Keep the childs arm extended while applying a Band-Aid to the site. b. Keep the childs arm extended and apply pressure to the site for a few minutes. c. Apply a Band-Aid to the site and keep the arm flexed for 10 minutes. d. Apply a gauze pad or cotton ball to the site and keep the arm flexed for several minutes.
B
The nurse is preparing to administer a liquid medication by a nasogastric feeding tube. What is the first thing the nurse should do? a. Check placement of the tube. b. Check the pH of the gastric aspirate. c. Flush the tube with a small amount of water. d. Give the medication and then flush with a small amount of water.
B
The nurse needs to start an intravenous (IV) line on an 8-year-old child to begin administering intravenous antibiotics. The child starts to cry and tells the nurse, Do it later, okay? What action should the nurse take? a. Postpone starting the IV until the next shift. b. Start the IV line and then allow for expression of feelings. c. Change the route of the antibiotics to PO. d. Postpone starting the IV line until the child is ready.
B
To facilitate the administration of an oral medication to a preschool-age child, what action should the nurse take? a. Dilute the medication in a large amount of favorite liquid and allow the child to hold the cup. b. Set limits about the need to take medication and offer praise immediately after the task is accomplished. c. Mix the medication in a moderate amount of the childs favorite food. d. Explain the purpose of the medication and allow the child time to express resistance before giving the medication.
B
A 14-year-old adolescent is hospitalized with cystic fibrosis. What nursing note entry represents best documentation of his breakfast meal? a. Tolerated breakfast well b. Finished all of breakfast ordered c. One pancake, eggs, and 240 ml OJ d. No documentation is needed for this age child.
C
A 2-year-old child is being admitted to the hospital for possible bacterial meningitis. When preparing for a lumbar puncture, what should the nurse do? a. Set up a tray with equipment the same size as for adults. b. Apply EMLA to the puncture site 15 minutes before the procedure. c. Prepare the child for conscious sedation being used for the procedure. d. Reassure the parents that the test is simple, painless, and risk free.
C
A 5-year-old child returns from the pediatric intensive care unit after abdominal surgery. The orders state to monitor vital signs every 2 hours. On assessment, the nurse observes that the childs heart rate is 20 beats/min less than it was preoperatively. What should be the nurses next action? a. Follow the orders and check in 2 hours. b. Ask the parents if this is the childs usual heart rate. c. Recheck the pulse and blood pressure in 15 minutes. d. Notify the surgeon that the child is probably going into shock.
C
A 6-year-old child needs to drink 1 L of GoLYTELY in preparation for a computed tomography scan of the abdomen. To encourage the child to drink, what should the nurse do? a. Give him a large cup with ice so it tastes better. b. Restrict him to his room until he drinks the GoLYTELY. c. Use little cups and make a game to reward him for each cup he drinks. d. Tell him that if he does not finish drinking by a set time, the practitioner will be angry.
C
A 7-year-old is identified as being at risk for skin breakdown. What intervention should the nursing care plan include? a. Massaging reddened bony prominences b. Teaching the parents to turn the child every 4 hours c. Ensuring that nutritional intake meets requirements d. Minimizing use of extra linens, which can irritate the childs skin
C
A child has a central venous access device for intravenous (IV) fluid administration. A blood sample is needed for a complete blood count, hemogram, and electrolytes. What is the appropriate procedure to implement for this blood sample? a. Perform a new venipuncture to obtain the blood sample. b. Interrupt the IV fluid and withdraw the blood sample needed. c. Withdraw a blood sample equal to the amount of fluid in the device, discard, and then withdraw the sample needed. d. Flush the line and central venous device with saline and then aspirate the required amount of blood for the sample.
C
A critically ill child has hyperthermia. The parents ask the nurse to give an antipyretic such as acetaminophen. How should the nurse respond to the parents? a. Febrile seizures can result. b. Antipyretics may cause malignant hyperthermia. c. Antipyretics are of no value in treating hyperthermia. d. Liver damage may occur in critically ill children.
C
A preschool child needs a dressing change. To prepare the child, what strategy should the nurse implement? a. Explain the procedure using medical terminology. b. Plan a 30-minute teaching session. c. Give choices when possible but avoid delay. d. Allow time after the procedure for questions and discussion.
C
An appropriate method for administering oral medications that are bitter to an infant or small child should be to mix them with which? a. Bottle of formula or milk b. Any food the child is going to eat c. One teaspoon of something sweet-tasting such as jam d. Carbonated beverage, which is then poured over crushed ice
C
Frequent urine tests for specific gravity are required on a 6-month-old infant. What method is the most appropriate way to collect small amounts of urine for these tests? a. Apply a urine collection bag to the perineal area. b. Tape a small medicine cup inside of the diaper. c. Aspirate urine from cotton balls inside the diaper with a syringe without a needle. d. Use a syringe without a needle to aspirate urine from a superabsorbent disposable diaper.
C
Parents are being taught how to feed their infant using a newly placed gastrostomy tube (G-tube). What is essential information for the parents to receive? a. Verify placement before each feeding. b. Use a syringe with a plunger to give the infant bolus feedings. c. Position the infant on the right side during and after the feeding. d. Beefy red tissue around the G-tube site must be reported to the practitioner.
C
The nurse is preparing a 9-year-old boy before obtaining a blood specimen by venipuncture. The child tells the nurse he does not want to lose his blood. What approach is best by the nurse? a. Explain that it will not be painful. b. Suggest to him that he not worry about losing just a little bit of blood. c. Discuss with him how his body is always in the process of making blood. d. Tell the child that he will not even need a Band-Aid afterward because it is a simple procedure.
C
The nurse is preparing to give acetaminophen (Tylenol) to a child who has a fever. What nursing action is appropriate? a. Retake the temperature in 15 minutes after giving the Tylenol. b. Place a warm blanket on the child so chilling does not occur. c. Check to be sure the Tylenol dose does not exceed 15 mg/kg. d. Use cold compresses instead of Tylenol to control the fever.
C
The practitioner has ordered a liquid oral antibiotic for a toddler with otitis media. The prescription reads 1 1/2 tsp four times per day. What should the nurse consider in teaching the mother how to give the medicine? a. A measuring spoon should be used, and the medication must be given every 6 hours. b. The mother is not able to handle this regimen. Long-acting intramuscular antibiotics should be administered. c. A hollow-handled medication spoon is advisable, and the medication should be equally spaced while the child is awake. d. A household teaspoon should be used and the medicine given when the child wakes up, around lunch time, at dinner time, and before bed.
C
Using knowledge of child development, what approach is best when preparing a toddler for a procedure? a. Avoid asking the child to make choices. b. Plan for a teaching session to last about 20 minutes. c. Demonstrate on a doll how the procedure will be done. d. Show the necessary equipment without allowing child to handle it.
C
What is the best method to verify the placement of a nasogastric tube before each use? a. Radiologic confirmation b. Auscultation of injected air c. Aspiration of stomach contents d. Verification of tape placement on tube
C
When checking the intravenous (IV) site on a child, the nurse should take which action? a. Look at the site. b. Ask the child if the site hurts. c. Look at the site while palpating the area. d. Take all the tape off, assess the site, and redress.
C
When teaching a mother how to administer eye drops, where should the nurse tell her to place them? a. At the lacrimal duct b. On the sclera while the child looks to the outside c. In the conjunctival sac when the lower eyelid is pulled down d. Carefully under the eyelid while it is gently pulled upward
C
. The nurse on a pediatric unit is writing guidelines for age-specific preparation of children for procedures based on developmental characteristics. What guideline is accurate? a. Inform toddlers about an upcoming procedure 2 hours before the procedure is to be performed. b. Inform school-age children about an upcoming procedure immediately before the procedure is scheduled to occur. c. Discourage parent presence during procedures on infants and toddlers. d. Use simple diagrams of anatomy and physiology to explain a procedure to a school-age child.
D