Chapter 72 Exam - NCLEX

The nurse monitors a 5 year-old child admitted to the hospital for a neuroblastoma for signs and symptoms related to the location of the tumor in the adrenal gland. Which descriptions would the nurse expect to be documented in the child's record specific to this tumor? Select all that apply. (2)

1. Firm, nontender, irregular mass in the abdomen 2. Urinary frequency or retention from compression on the bladder

The nurse has just administered ibuprofen to a child with a temperature of 38.8C (102F). The nurse should also take which action? 1. Withhold oral fluids for 8 hours. 2. Sponge the child with cold water. 3.Plan to administer salicylate (aspirin) in 4 hours. 4. Remove excess clothing and blankets from the child.

Remove excess clothing and blankets from the child.

The nurse reinforces instructions to the parents of a child with leukemia regarding measures related to monitoring for infection. Which statement by the parents indicates the need for further teaching?

"I need to take my child's rectal temperature daily"

The nurse has provided instructions to the mother of an infant with viral pneumonia. Which statement by the mother would indicate the need for further teaching?

"I understand I will need to have my baby on antibiotics for this pneumonia."

The nurse instructor asks a nursing student about phenylketonuria (PKU). Which statement made by the student indicates a need for further teaching?

"PKU primarily affects the gastrointestinal system."

The nurse caring for a child with aplastic anemia is reviewing the laboratory results and notes a white blood cell (WBC) count of 6000 mm3 (6 x 10^9/L) and a platelet count of 20,000 mm3 (20 x 10^9/L). Which nursing intervention should be incorporated into the plan of care?

Encourage quiet play activities

The nurse reinforces instructions to the parents of a child with sickle cell anemia regarding the precipitating factors related to pain crisis. Which, if identified by a parent as a precipitating factor, indicates the need for further teaching?

Fluid overload

A mother brings her 3-week-old infant to a clinic for a phenylketonuria rescreening blood test. The test indicates a serum phenylalanine level of 0 mg/dL (0 mcmol/L). The nurse reviews this result and makes which interpretation? 1. It is positive. 2. It is negative. 3. It is inconclusive. 4. It requires rescreening at age 6 weeks.

It is negative - It is characterized by blood phenylalanine levels greater than 20 mg/dL (12.1 mcmol/L) - NORM LEVEL is 0 to 2 mg/dL.

An infant returns to the nursing unit after the surgical repair of a cleft lip located on the right side of the lip. Which is the best position to place this infant at this time? 1.A flat position 2.A prone position 3.On his or her left side 4.On his or her right side

On his or her left side After the repair of a cleft lip, the infant should be positioned on the side opposite to the repair to prevent contact of the suture lines with the bed linens.

The nurse observes a mother giving an oral iron supplement to her 6-year-old child with iron deficiency anemia. Which action by the mother indicates the need for further teaching?

The mother administered the iron with milk

The nurse is assisting in performing pediculosis capitis (head lice) checks. Which finding indicates that a child has a "positive" head check?

White sacs attached to the hair shafts in the occipital area

The nurse reinforces instructions to the mother of a child who has been hospitalized with croup. Which statement made by the mother would indicate the need for further teaching?

"I will give my child cough syrup if a cough develops."

The nurse assists to prepare a teaching plan regarding the administration of eardrops for the parents of a 2-year-old child with otitis media. Which should be included in the plan?

Pull the earlobe down and back before instilling the eardrops

The nurse is monitoring for signs of dehydration in a 1-year-old child who has been hospitalized for diarrhea and prepares to take the child's temperature. Which method of temperature measurement should be avoided? 1.Rectal 2.Axillary 3.Electronic 4.Tympanic

Rectal

After a tonsillectomy, the child begins to vomit bright red blood. Which is the initial nursing action?

Turn the child to the side

The nurse reinforces home-care instructions to the parents of a child with hepatitis regarding the care of the child and the prevention of the transmission of the virus. Which statement by a parent indicates a need for further teaching? 1."Frequent hand washing is important." 2."I need to provide a well-balanced, high-fat diet to my child." 3."I need to clean contaminated household surfaces with bleach." 4."Diapers should not be changed near any surfaces that are used to prepare food.

" I need to provide a well-balanced, high-fat diet to my child."

The nurse reinforces home care instructions to the parents of a 3-year-old child who has been hospitalized with hemophilia. Which statement by a parent indicates the need for further teaching?

"I will avoid immunizations and dental hygiene treatments for my child."

The nurse has provided instructions to the mother of a child who has been diagnosed with bacterial conjuctivitis. Which statement by the mother would indicate the need for further teaching?

"I need to use hot compresses to relieve the eye irritation."

The nurse is reinforcing home-care instructions to the parents of a 3-year-old child with scabies. Which statement by a prent indicates the need for further teaching?

"I understand that I need to leave the scabicide on for 4 hours before washing it off."

The nurse is instructing a mother of a 1-year-old child with strabismus about the treatment options. Which statement by the mother would indicate the need for further teaching?

"My child will outgrow this by the time he is 2 years old and be able to see just fine."

The nursing instructor asks a student nurse to describe osteogenic sarcoma. Which statement by the student indicates the need for further research the disease?

"The child does not experience pain at the primary tumor site"

The nurse caring for a child who sustained a burn injury plans care based on which pediatric considerations associated with this injury? Select all that apply. (3)

1. A delay in growth may occur after a burn injury 2. An immature immune system presents an increased risk of infection for infants and young children 3. Infants and young children are at increased risk for protein and calorie deficiency because they have smaller muscle mass and less body fat than adults

A mother of a child with a diagnosis of intussusception calls the nurse into the hospital room because the child is screaming in pain. Which manifestations of perforation should the nurse report immediately? Select all that apply. 1.Fever 2.Ribbon-like stools 3.Increased heart rate 4.Hypoactive bowel sounds 5.Profuse projectile vomiting 6.Change in the level of consciousness

1. Fever 2. Increased heart rate 3. Change in the level of consciousness

The nurse is assigned to care for a child who is scheduled for an appendectomy. Which prescriptions does the nurse anticipate to be prescribed? Select all that apply. (4) 1.Administer a Fleet enema. 2.Initiate an intravenous line. 3.Maintain nothing-by-mouth status. 4.Administer intravenous antibiotics. 5.Administer preoperative medications. 6.Place a heating pad on the abdomen to decrease pain.

1. Initiate an intravenous line 2. Maintain nothing-by-mouth status 3. Administer intravenous antibiotics 4. Administer preoperative medications

The nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by the respiratory syncytial virus (RSV). Which interventions should be included in the plan of care? Select all that apply (2) 1. Place the infant in a private room. 2. Place the infant in a room near the nurses' station 3. Ensure that the infant's head is in a flexed position 4. Wear a mask at all times when in contact with the infant 5. Place the child in a tent that delivers warm, humidified air 6. Position the infant side-lying, with the head lower than the chest

1. Place the infant in a private room. 2. Place the infant in a room near the nurses' station

The school nurse prepares a list of home care instructions for the parents of school children who have been diagnosed with pediculosis capitis (head lice). Which should be included in the list? Select all that apply.

1. Siblings may also need treatment 2. Grooming items such as combs and brushes should not be shared 3. Launder all the bedding and clothing in hot water and dry on high heat 4. Vacuum floors, play areas, and furniture to remove any hairs that may carry live nits

The nurse is reviewing the postoperative primary health care provider's (PHCP'S) prescriptions for a 3-week-old infant with Hirschsprung's disease admitted to the hospital for surgery. Which prescriptions documented in the child's record should the nurse question? Select all that apply (2) 1. Measure abdominal girth daily. 2.Monitor strict intake and output. 3. Take temperature measurements rectally. 4. Start a clear liquid diet after 8 hours postoperative. 5. Maintain IV fluids until the child tolerates oral intake. 6. Monitor the surgical site for redness, swelling, and drainage.

1. Take temperature measurements rectally 2. Start clear liquid diet after 8 hours postoperative

Isoniazid is prescribed for a 2-year-old child with a positive tuberculin skin test. The mother of the child asks the nurse how long the child will need to take the medication. Which time frame is the appropriate response to the mother?

9 months

The nurse is caring for an 18-month-old child who has been vomiting. Which is the appropriate position to place the child during naps and sleep time? 1.A supine position 2.A side-lying position 3.Prone, with the head elevated 4.Prone, with the face turned to the side

A side-lying position

A topical corticosteroid is prescribed by the health care provider for a child with atopic dermatitis (eczema). Which instruction should the nurse give the parent about applying the cream?

Apply a thin layer of cream and rub it into the area thoroughly

The nurse reinforces instructions to the mother about dietary measures for a 5-year-old child with lactose intolerance. The nurse should tell the mother that which supplement will be required as a result of the need to avoid lactose in the diet? 1.Fats and vitamin A 2.Zinc and vitamin C 3.Calcium and vitamin D 4.Thiamine and vitamin B

Calcium and vitamin D - Lactose intolerance is the inability to tolerate lactose, the sugar that is found in dairy products. Removing milk from the diet can provide relief from symptoms. Additional dietary changes may be required to provide adequate sources of calcium and vitamin D.

A child has fluid volume deficit. The nurse collects data and determines that the child is improving and the deficit is resolving if which finding is noted? 1. The child has no tears. 2. Urine specific gravity is 1.030 3. Capillary refill is less than 2 seconds. 4. Urine output is less than 1 mL/kg/hour.

Capillary refill is less than 2 seconds

The nurse is instructing the mother of a child with cystic fibrosis (CF) about the appropriate dietary measures. Which meal best illustrates the most appropriate diet for a client with cystic fibrosis (CF)?

Chicken tenders and a baked potato with butter

A school-age child with type 1 diabetes mellitus has soccer practice three afternoons a week. The nurse reinforces instructions regarding how to prevent hypoglycemia during practice. Which should the nurse tell the child? 1. Eat twice the amount normally eaten at lunchtime. 2. Take half the amount of prescribed insulin on practice days. 3. Take the prescribed insulin at noontime rather than in the morning. 4. Eat a small box of raisins or drink a cup of orange juice before soccer practice.

Drink a half a cup of orange juice before soccer practice

The mother of a 6-year-old child who has type 1 diabetes mellitus calls a clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the child's urine and it was positive for ketones. The nurse should instruct the mother to take which action? 1. Hold the next dose of insulin. 2. Come to the clinic immediately. 3. Encourage the child to drink liquids 4. Administer an additional dose of regular insulin

Encourage the child to drink liquids - Liquids are essential to the clearing of ketones. Taking the child to the clinic immediately is unnecessary

A child with type 1 diabetes mellitus is brought to the emergency department by the mother, who states that the child has been complaining of abdominal pain and has been lethargic. Diabetic ketoacidosis is diagnosed. Anticipating the plan of care, the nurse prepares to administer which type of intravenous (IV) infusion? 1.Potassium infusion 2.NPH insulin infusion 3.5% dextrose infusion 4.Normal saline infusion

Normal saline infusion - Hyperglycemia occurs with DKA. Rehydration is the initial step. Dextrose solutions are added when the glucose gets back to a stable level. IV potassium may be required, but it would not be part of the initial infusions

A child with a diagnosis of a hernia has been scheduled for a surgical repair in 2 weeks. The nurse reinforces instructions to the parents about the signs of possible incarcerated hernia. The nurse tells the parents that which manifestation requires primary health care provider (PHCP) notification by the parents? 1.Pain 2.Diarrhea 3.Constipation 4.Increased flatus

Pain

A 4-year-old child is hospitalized with a suspected diagnosis of Wilms' tumor. The nurse reviews the plan of care and should question which intervention that is written in the plan?

Palpate the abdomen for a mass

The nursing instructor asks a nursing student about sudden infant death syndrome (SIDS). Which statement by the student indicates further teaching is needed?

"The incidence of SIDS has been found to be higher in breastfed infants and infants that use a pacifier."

A child is brought to the emergency room and the mother reports that the child accidentally swallowed paint thinner after mistaking it for water. The nurse should perform which action first? 1. Begin resuscitation 2. Terminate exposure to the poison 3. Take measures to prevent absorption of the poison 4. Check the circulation, airway, and breathing status of the child

Check the circulation, airway, and breathing status of the child.

A health care provider prescribes an intravenous (IV) solution of 5% dextrose and half-normal saline (0.45%) with 40 mEq of potassium chloride for a child with hypotonic dehydration. The nurse performs which priority assessment before administering this IV prescription? 1. Obtains a weight 2. Takes the temperature 3. Takes the blood pressure 4. Checks the amount of urine output

Checks the amount of urine output

The nurse reviews the record of an infant who is seen in the clinic. The nurse notes that a diagnosis of esophageal atresia with tracheoesophageal fistula (TEF) is suspected. The nurse expects to note which most likely manifestation of this condition in the medical record? 1.Incessant crying 2.Coughing at nighttime 3.Choking with feedings 4.Severe projectile vomiting

Choking with feedings

The nurse is assigned to care for a child after a myringotomy with the insertion of tympanostomy tubes. The nurse notes a small amount of reddish drainage from the child's ear after the surgery. On the basis of this finding, which action should the nurse take?

Document the findings

The nurse is reviewing the record of a child with a diagnosis of pyloric stenosis. Which data should the nurse expect to note as having been documented in the child's record? 1.Watery diarrhea 2.Projectile vomiting 3.Increased urine output 4.Vomiting large amounts of bile

Projectile vomiting - Pyloric stenosis is a problem that affects babies between birth and 6 months of age and causes forceful vomiting that can lead to dehydration.

An adolescent client with type 1 diabetes mellitus is admitted to the emergency department for treatment of diabetic ketoacidosis. Which assessment findings should the nurse expect to note? 1. Sweating and tremors 2. Hunger and hypertension 3. Cold, clammy skin and irritability 4. Fruity breath odor and decreasing level of consciousness

Fruity breath odor and decreasing level of consciousness

The nurse is working in the emergency department and is caring for a child who has been diagnosed with epiglottitis. Which is an indication that the child may be experiencing airway obstruction?

Tripod positioning and dyspnea

The nurse reinforces home-care instructions to the parents of a child with celiac disease. Which food item should the nurse advise the parents to include in the child's diet? 1.Rice 2.Oatmeal 3.Rye toast 4.Wheat bread

Rice - Dietary management is the mainstay of treatment for celiac disease. All wheat, rye, barley, and oats should be eliminated from the diet and replaced with corn and rice. Vitamin supplements, especially fat-soluble vitamins and folate, may be required during the early period of treatment to correct deficiencies. These restrictions are likely to be life long, although small amounts of grains may be tolerated after the gastrointestinal ulcerations have healed.

The nurse reinforces instructions to the mother of a child with croup about the measures to take if an acute spasmodic episode occurs. Which statement by the mother indicates the need for further teaching?

"I will place a steam vaporizer in my child's bedroom"

The nurse is providing discharge instructions to the parents of a 14-year-old child who is undergoing radiation for Hodgkin's disease. Which statement by a parent indicates the need for further teaching?

"I will need to keep my child's skin from flaking, so we will be allowing showers every 2 or 3 days."

The nurse should implement which interventions for a child older than 2 years with type 1 diabetes mellitus who has a blood glucose level of 60 mg/dL (3.4 mmol/L)? Select all that apply (2) 1. Administer regular insulin. 2. Encourage the child to ambulate. 3. Give the child a teaspoon of honey. 4. Provide electrolyte replacement therapy intravenously. 5. Wait 30 minutes and confirm the blood glucose reading.6. Prepare to administer glucagon subcutaneously if unconsciousness occurs.

1. Give the child a teaspoon of honey 2. Prepare to administer glucagon subcutaneously if unconsciousness occurs

The nurse is monitoring for bleeding in a child after surgery to remove a brain tumor. The nurse checks the head dressing for the presence of blood and notes a colorless drainage on the back of the dressing. Which nursing action is appropriate?

Notify the registered nurse (RN)