exam 1 - nclex practice questions
The nurse is caring for a 2-year-old child who was admitted to the pediatric floor for moderate dehydration due to vomiting and diarrhea. The child is restless, with periods of irritability. The child is afebrile with a heart rate of 148 and a blood pressure of 90/42. The parents state that the child has not had a wet diaper for 12 hours. After establishing a saline lock, the nurse reviews the physician's orders. Which order should the nurse question? A. After the saline bolus, begin maintenance fluids of D5 ¼ NS with 10 mEq KCL/L B. Administer a saline bolus of 10ml/kg, which may be repeated if the child does not urinate. C. Recheck serum electrolytes in 12 hours. D. Give clear liquid diet as tolerated.
A. After the saline bolus, begin maintenance fluids of D5 ¼ NS with 10 mEq KCL/L
A 4-month-old has had vomiting and diarrhea for 24 hours. The infant is fussy and the anterior fontanel is sunken. The nurse notes that the infant does not produce tears when crying. Which task will help confirm the diagnosis of dehydration? A. Analysis of serum electrolytes B. Urinalysis obtained by bagged specimen C. Urinalysis obtained by sterile catheterization D. Analysis of CBC
A. Analysis of serum electrolytes
Hydrotherapy is required to treat a child with extensive partial-thickness burn wounds. The nurse knows the primary purpose of hydrotherapy is to: A. Debride the wounds. B. Increase peripheral blood flow. C. Provide pain relief D. Destroy bacteria on the skin.
A. Debride the wounds.
The mother of a 3-year-old child arrives at a clinic and tells the nurse that the child has been scratching the skin continuously and has developed a rash. The nurse assesses the child and suspects the presence of scabies. The nurse bases this suspicion on which finding noted on assessment of the child's skin? A. Fine grayish-red lines B. Purple colored lesions C. Thick, honey colored crusts D. Clusters of fluid-filled vesicles
A. Fine grayish-red lines
The nurse is caring for a 4-month-old with gastroesophageal reflux (GER). The infant is due to receive Prevacid (lansoprazole). Based on the medication's mechanism of action, when should this medication be administered? A. Immediately before a feeding B. 30 minutes after the feeding C. In the morning on an empty stomach D. At bedtime
A. Immediately before a feeding
A nurse is teaching a group of parents about Salmonella. Which of the following should the nurse include in the teaching? Select all that apply. A. It is a bacterial infection B. Bloody diarrhea is common C. Incubation period is nonspecific. D. Antibiotics are always used for treatment. E. Transmission can be from house pets.
A. It is a bacterial infection B. Bloody diarrhea is common E. Transmission can be from house pets.
A nurse is teaching a group of parents about E. Coli. Which of the following information should the nurse include in the teaching? Select all that apply. A. It is a foodborne pathogen. B. Severe abdominal cramping occurs. C. It can lead to hemolytic uremic syndrome. D. Watery diarrhea is present for more than 5 days. E. Antibiotics are given for treatment.
A. It is a foodborne pathogen. B. Severe abdominal cramping occurs. C. It can lead to hemolytic uremic syndrome.
The nurse is preparing for the admission of an infant with a diagnosis of bronchiolitis caused by respiratory syncytial virus (RSV). Which interventions should the nurse include in the plan of care? Select all that apply. A. Place the infant in a private room or in a room with another child with RSV. B. Ensure the infant's head is in a flexed position at all times. C. Place the infant in a tent that delivers warm humidified air. D. Position the child on the side, with the head lower than the chest. E. Ensure that nurses caring for the infant with RSV do not care for other high-risk children.
A. Place the infant in a private room or in a room with another child with RSV. E. Ensure that nurses caring for the infant with RSV do not care for other high-risk children.
A nurse is caring for a child who has Hirschsprung's disease. Which of the following actions should the nurse take? A. Prepare the family for surgery. B. Initiate bed rest C. Place an NG tube for decompression D. Encourage a high-fiber, low protein, low calorie diet.
A. Prepare the family for surgery.
What therapeutic interventions will Sarah's parents need to include to support her with her cystic fibrosis (CF) diagnosis? Select all that apply. A. Providing a high-protein, high fat, high calorie diet. B. Providing a low-fat, low carbohydrate diet. C. Providing additional calcium, salt, iron, and zinc in diet D. Encouraging exercise. E. Minimizing pulmonary complications. F. Encouraging medication compliance.
A. Providing a high-protein, high fat, high calorie diet. C. Providing additional calcium, salt, iron, and zinc in diet D. Encouraging exercise. E. Minimizing pulmonary complications. F. Encouraging medication compliance.
A six-week-old is admitted to the pediatric floor with influenza. The child is crying and the father tells the nurse his son is hungry. The nurse explains that the child is not to have anything by mouth. The parent does not understand why the child cannot eat. What is the best response by the nurse? A. "We are giving your child intravenous fluids, so there is no need for anything by mouth." B. "The shorter and narrower airway of the infants increases their chances of aspiration, so your child should not have anything to eat now." C. "When your child eats, he burns too many calories. We want to conserve your child's energy." D. "Your child has too much nasal congestion. If we feed the child by mouth, the distress will likely increase."
B. "The shorter and narrower airway of the infants increases their chances of aspiration, so your child should not have anything to eat now."
The nurse caring for a child who has sustained a burn injury plans care based on which pediatric considerations associated with this injury? Select all that apply. A. Scarring is less severe in a child than an adult. B. A delay in growth may occur after a burn injury. C. An immature immune system presents an increased risk of infection for infants and young children. D. The lower portion of body fluid to mass in a child increases the risk of cardiovascular problems. E. Fluid resuscitation is unnecessary unless the burned area is more than 25% of the total body surface area. F. 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.
B. A delay in growth may occur after a burn injury. C. An immature immune system presents an increased risk of infection for infants and young children. F. 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.
Which should be included in the plan of care of a 14-month-old whose cleft palate was repaired 12 hours ago? Select all that apply. A. Once liquids have been tolerated, encourage a bland diet such as Jell-O and saltine crackers. B. Administer pain medication on a regular schedule as opposed to an as-needed schedule. C. Use a Yankauer suction catheter on the infant's mouth to decrease the risk of aspiration of oral secretions. D. When discharged, remove elbow restraints. E. Allow the infant to have familiar items of comfort, such as a favorite stuffed animal and a soft, short tipped "sippy" cup.
B. Administer pain medication on a regular schedule as opposed to an as-needed schedule. E. Allow the infant to have familiar items of comfort, such as a favorite stuffed animal and a soft, short tipped "sippy" cup.
Which would be a priority intervention for a child diagnosed with varicella (chickenpox) who was prescribed diphenhydramine (Benadryl) for itching? A. Give a warm bath with mild soap before lotion application. B. Avoid Caladryl lotion while taking diphenhydramine (Benadryl). C. Apply Caladryl lotion generously to decrease itching. D. Give a cool shower with mild soap to decrease itching.
B. Avoid Caladryl lotion while taking diphenhydramine (Benadryl).
Which manifestation suggests that an infant is developing necrotizing enterocolitis (NEC)? A. Decreased residuals prior to feedings B. Bloody diarrhea C. Hyperactive bowel sounds D. Decreased abdominal girth prior to feedings
B. Bloody diarrhea
The nurse reviews the record of a newborn infant and notes that a diagnosis of esophageal atresia with tracheoesophageal fistula is suspected. The nurse would most likely expect to see which common presentation of this condition is documented in the EHR? A. Incessant crying B. Choking with feedings C. Coughing at nighttime D. Severe projectile vomiting
B. Choking with feedings
Which would be the priority intervention for a child suspected of having varicella (chickenpox)? A. Contact precautions B. Contact and airborne respiratory precautions C. Droplet respiratory precautions D. Universal precautions and standard precautions
B. Contact and airborne respiratory precautions
A toddler sustains a minor burn on the hand from hot coffee. What would be the first action in treating this burn? A. Apply ice to the burned area. B. Hold the burned area under cool running water. C. Break any blisters with a sterile needle. D. Apply an antimicrobial ointment.
B. Hold the burned area under cool running water.
A 10-year-old is being evaluated for possible appendicitis and complains of nausea and sharp abdominal pain in the right lower quadrant. The child vomits, finds the pain relieved and calls the nurse. What is the nurse's priority action? A. Cancel the ultrasound and obtain an order for oral Zofran (ondansetron). B. Immediately notify the physician of the child's status. C. Cancel the ultrasound and prepare to administer an intravenous bolus. D. Prepare for probable discharge of patient.
B. Immediately notify the physician of the child's status.
In order to increase compliance with the acne treatment regimen for a teenager, the nurse should include what information in the education plan? A. Teenagers must be responsible for their own treatment and must be trusted to follow through and be compliant. B. It often takes up to 12 weeks to see an improvement and a response to treatment. C. Apply sunscreen every morning and anti-acne medication every night. D. Teach parents to praise the good habits of the teenager.
B. It often takes up to 12 weeks to see an improvement and a response to treatment.
The nurse is caring for a 7-week-old infant scheduled for a pyloromyotomy in 24 hours. Which would the nurse expect to see in the plan of care? A. Keep infant NPO; begin intravenous fluids at ½ maintenance. B. Keep infant NPO; begin intravenous fluids at maintenance; place nasogastric tube (NGT) to low wall suction. C. Obtain serum electrolytes; keep infant NPO; do not attempt to pass NGT due to obstruction. D. Offer infants small, frequent feedings; keep NPO 2-4 hours before surgery.
B. Keep infant NPO; begin intravenous fluids at maintenance; place nasogastric tube (NGT) to low wall suction.
A nurse is caring for a child who has Meckel's Diverticulum. Which of the following manifestations should the nurse expect? Select all that apply. A. Rapid, shallow breathing. B. Mucous, bloody stools. C. Abdominal pain. D. Fever E. Dark, tarry stools
B. Mucous, bloody stools. C. Abdominal pain.
The nurse is monitoring a child with burns during treatment for burn shock. The nurse recognizes that which assessment provides the most accurate guide to determine the adequacy of fluid resuscitation? A. Skin turgor B. Neurological assessment C. Level of edema at the burn site D. Quality of peripheral pulses
B. Neurological assessment
Which discharge instruction for a child diagnosed with encopresis should the nurse question? A. Limit the intake of milk. B. Offer a diet high in protein. C. Obtain a complete dietary log. D. Follow up with a child psychologist.
B. Offer a diet high in protein.
The nurse provides feeding instructions to a parent of an infant diagnosed with gastroesophageal reflux. Which instruction should the nurse give to the parent to assist in reducing the episodes of emesis? A. Feed the infant in the supine position. B. Provide more frequent, smaller feedings. C. Burp the infant less frequently during feedings. D. Thin the feedings by adding water to the formula.
B. Provide more frequent, smaller feedings.
Which interventions should the nurse include when preparing a care plan for a child with hepatitis? Select all that apply A. Notifying the health care provider (HCP) if jaundice is present. B. Providing a low-fat, well-balanced diet. C. Teaching the child effective hand-washing techniques. D. Instructing the parents to avoid administering medications unless prescribed. E. Arranging for indefinite homeschooling because the child will not be able to return to school.
B. Providing a low-fat, well-balanced diet. C. Teaching the child effective hand-washing techniques. D. Instructing the parents to avoid administering medications unless prescribed.
How does the nurse interpret the laboratory analysis of Sarah's stool sample containing excessive amounts of azotorrhea and steatorrhea? A. She is not compliant with taking her vitamins. B. She is not compliant with taking her enzymes. C. She is eating too many foods high in fat. D. She is eating too many foods high in fiber.
B. She is not compliant with taking her enzymes.
Which would be an early sign of distress in a 2-month-old child? A. Shallow respirations B. Tachypnea C. Tachycardia D. Bradycardia
B. Tachypnea
Sarah's parents are excited about the possibility of her receiving a double lung transplant. What is important for Sarah's parents to understand? A. The transplant will cure Sarah of CF and allow her to live a long and healthy life. B. The transplant will not cure Sarah of CF but will allow her to have a longer life. C. The transplant will help to reverse the multisystem damage that has been caused by VF. D. The transplant will be Sara's only chance at surviving long enough to graduate college.
B. The transplant will not cure Sarah of CF but will allow her to have a longer life.
Which assessment is of greatest concern in a 15-month-old child? The child... A. is lying down, has moderate retractions, low-grade fever, and nasal congestion. B. has diminished breath sounds, no cough, and has a protruding tongue with drooling. C. is sitting up and has coarse breath sounds, coughing, and fussiness. D. is restless and crying, has bilateral wheezing, and is feeding poorly.
B. has diminished breath sounds, no cough, and has a protruding tongue with drooling.
An emergency department nurse is caring for a child diagnosed with epiglottitis. In assessing the child, the nurse should monitor for which indication that the child may be experiencing airway obstruction? The child is... A. exhibiting nasal flaring and tachycardia. B. leaning forward with the chin thrust out and drooling. C. has a low grade fever and complains of a sore throat. D. is leaning backward, supporting themselves with the hands and arms.
B. leaning forward with the chin thrust out and drooling.
The mother of a hospitalized 2-year-old child with viral laryngotracheobronchitis (croup) asks the nurse why the health care provider did not prescribe antibiotics. Which response should the nurse provide? A. "Your child may be allergic to antibiotics." B. "Your child is too young to receive antibiotics." C. "Antibiotics are not indicated unless there is a bacterial infection." D. "Your child still has maternal antibodies from birth and does not does not need antibiotics."
C. "Antibiotics are not indicated unless there is a bacterial infection."
The nurse is caring for a 3-month-old infant with short bowel syndrome (SBS). The parent asks how the disease will affect their child. The best response by the nurse would be: A. "Because your child has a shorter intestine than most, your child will likely experience constipation and will need to be placed on a bowel regimen." B. "Unfortunately, most children with this diagnosis do not do very well." C. "Because your child has a shorter intestine than most, he will not be able to absorb all the nutrients and vitamins in food and will need to get nutrients in other ways." D. "The prognosis and course of the disease have changed because hyperalimentation is available."
C. "Because your child has a shorter intestine than most, he will not be able to absorb all the nutrients and vitamins in food and will need to get nutrients in other ways."
The school nurse has provided an instructional session about impetigo to parents of the children attending the school. Which statement, if made by a parent, indicates a need for further instruction? A. "It is extremely contagious." B. "It is common in humid weather." C. "Lesions are located on the back, abdomen, and extensor surfaces." D. "It might start up in an area of broken skin, such as an insect bite."
C. "Lesions are located on the back, abdomen, and extensor surfaces."
Sarah's parents ask the nurse what will need to be done to relieve her constipation. What is the nurse's best response? A. "Sarah likely has an obstruction and will need surgery." B. "Sarah will likely be given IV fluids." C. "Sarah will likely be given MiraLAX." D. "Sarah will be placed on a clear liquid diet."
C. "Sarah will likely be given MiraLAX."
Which child with pneumonia would benefit most from hospitalization? A. 13-year-old who is coughing, has coarse breath sounds, and is not sleeping well. B. 14-year-old with a fever of 38.6°C (101.5°F), rapid breathing and a decreased appetite. C. 15-year-old who has been vomiting for 3 days and has a fever of 38.5°C (101.3°F). D. 16-year-old who has a cough, chills, fever of 38.5°C (101.3°F), and wheezing.
C. 15-year-old who has been vomiting for 3 days and has a fever of 38.5°C (101.3°F).
Which manifestations would the nurse expect to see in a 4-week-old infant with biliary atresia? A. Abdominal distention, multiple bruises, and hematuria. B. Yellow sclera and skin tones, excessively oily skin, and prolonged bleeding times. C. Abdominal distention, enlarged liver, enlarged spleen, clay-colored stool, and tea-colored urine. D. No manifestations until the disease has progressed to the advanced stage.
C. Abdominal distention, enlarged liver, enlarged spleen, clay-colored stool, and tea-colored urine.
A 6-year-old child is having burn care following premedication for pain. The child is not cooperative for dressing changes and begins screaming and kicking. What is the best action by the nurse? A. Inform the child that cooperation is necessary for proper healing and will shorten the hospital stay. B. Allow the parents to change the dressings with coaching from the nurse. C. Allow the child to participate in the dressing change process as much as possible. D. Inform the child that restraints will be used if there is no cooperation.
C. Allow the child to participate in the dressing change process as much as possible.
Which child is at highest risk for requiring hospitalization to treat respiratory syncytial virus (RSV)? A. A 2-month-old who was born at 36 weeks. B. A 16-month-old with a tracheostomy. C. An 18 month-old with a congenital heart defect. D. A 4-year-old who was born at 30 weeks.
C. An 18 month-old with a congenital heart defect.
Which breathing exercises should the nurse have an asthmatic 3-year-old do to increase her expiratory phase? A. Use an incentive spirometer. B. Breathe into a paper bag. C. Blow a pinwheel. D. Take several deep breaths.
C. Blow a pinwheel.
Which of the following is one of the first signs of overwhelming sepsis in a child with burn injuries? A. Seizures B. Bradycardia C. Disorientation D. Decreased blood pressure
C. Disorientation
The nurse is caring for a newborn with a suspected diagnosis of imperforate anus. The nurse monitors the infant, knowing that which is a clinical manifestation of this disorder? A. Bile-stained fecal emesis B. The passage of currant jelly-like stools C. Failure to pass meconium stool in the first 24 hours after birth D. Sausage-shaped mass palpated in the upper right abdominal quadrant
C. Failure to pass meconium stool in the first 24 hours after birth
The clinic nurse is reviewing discharge instructions to parents of a child diagnosed with scabies and prescribed a scabicide. Which statement by the parents indicates a need for further teaching? (what's the wrong answer) A. I will need to wash all of my child's bedding daily in hot water and dry them in the dryer on high heat. B. To prevent spreading to other members of our family, we need to limit physical skin to skin contact until he finishes treatment. C. I should avoid applying the scabicide to my child's hands because he frequently sucks his thumb and it is dangerous to ingest this medication. D. It is important that this medication remains on his skin for a minimum of 8 hours.
C. I should avoid applying the scabicide to my child's hands because he frequently sucks his thumb and it is dangerous to ingest this medication.
Which of the following explains physiologically the edema formation that occurs with burns? A. Vasoconstriction B. Decreased capillary permeability C. Increased capillary permeability D. Decreased hydrostatic pressure within capillaries
C. Increased capillary permeability
A nurse is caring for a child who is suspected to have Enterobius vermicularis. Which of the following actions should the nurse take? A. Initiate IV fluids B. Test the stool for occult blood C. Perform a tape test D. Collect a stool specimen for culture.
C. Perform a tape test
The nurse is planning care for a 3-month-old infant with eczema. Which intervention would take the highest priority? A. Maintaining adequate hydration B. Keeping the baby content C. Preventing infection of the lesions D. Applying antibiotics to lesions
C. Preventing infection of the lesions
Which assessment of an 18-month-old with burns on his feet would cause suspicion of child abuse? A. Splash marks on his right lower leg B. Burns noted on right arm C. Symmetrical burns on both feet D. Burns mainly noted on right foot
C. Symmetrical burns on both feet
The nurse knows that the Nissen fundoplication involves which of the following? A. The fundus of the stomach is wrapped around the inferior stomach, mimicking a lower esophageal sphincter. B. The fundus of the stomach is wrapped around the middle portion of the stomach, decreasing the capacity of the stomach. C. The fundus of the stomach is wrapped around the inferior esophagus, mimicking a cardiac sphincter. D. The fundus of the stomach is dilated, decreasing the likelihood of reflux.
C. The fundus of the stomach is wrapped around the inferior esophagus, mimicking a cardiac sphincter.
A nurse is assessing a child who has a rotavirus infection. Which of the following are expected findings? Select all that apply. A. Confusion B. Bloody stools C. Vomiting D. Fever E. Watery stools
C. Vomiting D. Fever E. Watery stools
Sarah's parents wanted to have more children but were concerned about the possibility of other children being born with CF. They are referred to a geneticist and the nurse in that office is able to explain the inheritance of CF. She knows to explain that CF is an: A. autosomal-dominant trait passed on from the child's mother. B. autosomal-dominant trait passed on by the child's father. C. autosomal-recessive trait passed on by both parents who are carriers and that each child has a 25% chance of having CF. D. autosomal-recessive trait passed on by both parents who are carriers and that each child has a 50% chance of having CF.
C. autosomal-recessive trait passed on by both parents who are carriers and that each child has a 25% chance of having CF.
The parent of a 9-month-old child with croup tells the nurse that her older child just had croup and it cleared up in a couple of days without intervention. She asks the nurse why this child is exhibiting worse symptoms and needs to be hospitalized. The nurse's best response is... A. "Some children just react differently to viruses. It is best to treat each child as an individual." B. Younger children have wider airways that make it easier for bacteria to enter and colonize." C. "Younger children have short, wide eustachian tubes, making them more susceptible to respiratory infections." D. "Children younger than 3 years usually exhibit worse symptoms because their immune systems are not as developed."
D. "Children younger than 3 years usually exhibit worse symptoms because their immune systems are not as developed."
The nurse caring for a hospitalized 8-year-old child being treated for right lower lobe pneumonia is providing teaching for the parents regarding the best positioning for improved lung aeration. The best recommendation by the nurse is: A. "Place child in the Trendelenberg position." B. "Place the child in a prone position." C. "Encourage your child to lie on the right side with the elevated head of the bed." D. "Encourage your child to lie on their left side with the elevated head of the bed."
D. "Encourage your child to lie on their left side with the elevated head of the bed."
Sarah was 5 weeks old when she was diagnosed with CF. Her mother had a close cousin who died of CF when she was 14 years old. Sarah's parents were sad and concerned about Sarah's current life expectancy. What is the nurse's best response? A. "The life expectancy for CF patients has improved significantly in recent years." B. "Your child might not follow the course that the mother's cousin did." C. "The physician will come to speak to you about treatment options." D. "Let's talk about your questions and concerns. We also have a parent support group that you may be interested in."
D. "Let's talk about your questions and concerns. We also have a parent support group that you may be interested in."
The parent of a 9-month-old calls the ER because his child is choking on a marble. The parent asks how to help his child while awaiting Emergency Medical Services (EMS). Which is the nurse's best response? A. "You should administer five abdominal thrusts followed by five back blows." B. "You should try to retrieve the object by inserting your finger in your child's mouth." C. "You should provide the Heimlich maneuver." D. "You should administer five back blows followed by five chest thrusts."
D. "You should administer five back blows followed by five chest thrusts."
The clinic nurse is providing instructions to a parent of a child with cystic fibrosis regarding the immunization schedule for the child. Which statement by the nurse to the parent is most appropriate? "Your child will... A. "need to have their immunization schedule altered." B. "should not receive any hepatitis vaccines." C. "receive all the immunizations except for the polio series." D. "receive the recommended basic series of immunizations along with the yearly influenza vaccination."
D. "receive the recommended basic series of immunizations along with the yearly influenza vaccination."
A topical corticosteroid is prescribed by the healthcare provider of a child with atopic dermatitis (eczema). Which instruction should the nurse give the parent about applying the cream? A. Apply the cream over the entire body. B. Apply a thick layer of cream to the affected areas only. C. Avoid cleansing the area prior to application of the cream. D. Apply a thin layer of cream and rub it into the area thoroughly.
D. Apply a thin layer of cream and rub it into the area thoroughly.
Permethrin (Elemite) is prescribed for a child with the diagnosis of scabies. The nurse should give which instruction to the parents regarding the use of this treatment? A. Apply the lotion to areas of the rash only. B. Apply the lotion to affected areas and leave it on for 6 hours. C. Avoid putting clothes on the child over the lotion. D. Apply the lotion to cool, dry skin at least 30 minutes after bathing.
D. Apply the lotion to cool, dry skin at least 30 minutes after bathing.
A nurse is caring for a child who has had watery diarrhea for the past 3 days. Which of the following is an appropriate action for the nurse to take? A. Keep NPO until the diarrhea subsides. B. Start hypertonic IV solution C. Offer chicken broth. D. Initiate oral rehydration therapy
D. Initiate oral rehydration therapy
A child is hospitalized because of persistent vomiting. The nurse should monitor the child closely for which problem? A. Diarrhea B. Metabolic acidosis C. Hyperactive bowel sounds D. Metabolic alkalosis
D. Metabolic alkalosis
A nurse is caring for an infant who is 4 hours postoperative following cleft lip and palate repair. Which of the following actions should the nurse take? A. Offer a pacifier with sucrose. B. Remove the packing in the mouth C. Assess the mouth with a tongue blade D. Place the infant in an upright position
D. Place the infant in an upright position
An adolescent girl is cooking on a gas stove when her bathrobe catches fire. Her father smothers the flames with a rug and calls an ambulance. She has sustained major burns over much of her body. Which of the following actions are also important in her immediate care? Select all that apply A. Wrap her in a blanket until help arrives. B. Encourage her to drink clear liquids. C. Place her in a tub of cool water. D. Remove her burned clothing and jewelry.
D. Remove her burned clothing and jewelry.
The school nurse is conducting pediculosis capitis (head lice) assessments. Which finding indicates a child has a "positive" head check? A. Maculopapular lesions behind the ears B. Lesions in the scalp that extend to the hairline or neck. C. White, flaky particles throughout the entire scalp area. D. White sacs attached to the hair shafts in the occipital area.
D. White sacs attached to the hair shafts in the occipital area.
When Sarah is diagnosed with CF, her parents ask what early respiratory symptoms they should expect to see. The nurse's best response would be: "You can expect her to develop... A. a barrel-shaped chest." B. a chronic, productive cough." C. bronchiectasis." D. wheezing respirations."
D. wheezing respirations."
The clinical manifestations common to the child with cystic fibrosis include. Select all that apply. Meconium ileus at birth Delayed growth Bulky, greasy stools Voracious appetite Increased weight Chronic cough Barrel-shaped chest
Meconium ileus at birth Delayed growth Bulky, greasy stools Chronic cough Barrel-shaped chest
The nursing management of a child with cystic fibrosis should include (select all that apply): Minimizing pulmonary complications Promoting growth and development Facilitating coping of child and family Promoting child's self-esteem
Minimizing pulmonary complications Promoting growth and development Facilitating coping of child and family Promoting child's self-esteem
You are caring for a child with cystic fibrosis who receives pancreatic enzymes with large snacks and meals. Which statement by the mother demonstrates good understanding of the proper administration of the supplemental enzymes? "I will stop the enzymes if my child is given any antibiotics." "I will decrease the dose by half if my child is having greasy stools." "I will give the enzymes between meals to provide the best absorption." "I will give the enzymes at the beginning of every meal and large snack."
"I will give the enzymes at the beginning of every meal and large snack."
Which child may need extra fluids to prevent dehydration? Select all that apply. A. 7-day-old receiving phototherapy B. A 13-year-old who has just started her menses C. 6-week-old with newly diagnosed pyloric stenosis D. 2-year-old with pneumonia E. 2-year-old with full-thickness burns to chest, back and abdomen
A. 7-day-old receiving phototherapy C. 6-week-old with newly diagnosed pyloric stenosis D. 2-year-old with pneumonia E. 2-year-old with full-thickness burns to chest, back and abdomen
Who is at the highest priority to receive the inactivated flu vaccine? A. A healthy 8-month-old who attends day care. B. An 8-year-old who previously had Guillain Barre Syndrome (GBS). C. A 7-year-old who attends public school. D. A 17-year-old who is living in a college dormitory.
A. A healthy 8-month-old who attends day care.
Which child with asthma should the nurse see first? A. A 12-month-old who has a mild cry, is pale in color, has diminished breath sounds, and has an oxygen saturation of 90% on room air. B. A 5-year-old who is speaking in complete sentences, is pink in color, is wheezing bilaterally, and has an oxygen saturation of 95% on room air. C. A 9-year-old who is quiet, is pale in color, is wheezing bilaterally with an oxygen saturation of 94% on room air. D. A 16-year-old who is speaking in short sentences, is wheezing, is sitting in a tripod position, and has an oxygen saturation of 93% on room air.
A. A 12-month-old who has a mild cry, is pale in color, has diminished breath sounds, and has an oxygen saturation of 90% on room air.
When assessing the history of a child recently diagnosed with atopic dermatitis, which question is important to ask the parents? A. "Does your child have any allergies to foods or other substances?" B. "Has your child ever had these symptoms before?" C. "Has your child had any cystic lesions?" D. "Are your child's immunizations up to date?"
A. "Does your child have any allergies to foods or other substances?"
When Sarah was 4 months old and had already been diagnosed with cystic fibrosis, her parents were learning about interventions they needed to incorporate into her daily routine to promote her best help. One of the questions they had was when to begin Sarah's first chest physiotherapy (CPT) of each day. The nurse's best response would be: A. "Thirty minutes before feeding your child breakfast." B. "After deep-suctioning your child each morning." C. "Thirty minutes after feeding your child breakfast." D. "Only when your child has congestion or coughing."
A. "Thirty minutes before feeding your child breakfast."
Sarah's parents ask the nurse in the CF clinic how best to meet her increased nutritional needs when she was an infant. What is the nurse's best response? A. "You may need to change Sarah to a higher calorie formula." B. "You may need to increase the number of fresh fruits and vegetables you give Sarah." C. "You may need to advance Sarah's diet to whole cow's milk because it is higher in fat than formula." D. "You may need to increase Sarah's carbohydrate intake."
A. "You may need to change Sarah to a higher calorie formula."
