final study guide
A nurse is caring for a 2 month old infant who is brought to the clinic for routine immunizations. Which of the following should the nurse administer? a. HIB, Td, HBV, IPV b. DTaP, MMR, IPV c. DTaP HIB, IPV, HBV d. HIB, MMR, Td, IPV
c. DTaP HIB, IPV, HBV
Early interventions for autism
*PT/OT *speech & language therapy
Pediatric Emergencies: Treatment for an Overdose of Acetaminophen (Ch. 42)
-2-4 hrs after ingestion- N,V,sweating and pallor -24-36 hrs after - improvement in conditions 36 hr-7 days- hepatic stage - pain in URQ, confusion, stupor, jaundice, coagulation disturbances -TX WITH N-acetylcysteine (Mucomyst) given orally
How do you administer iron elixir patient teaching
-Give 1 hr before or 2 hr after mild or antacid to prevent decreased absorption -GI upset (diarrhea, constipation, nausea) is common at the start of therapy -if tolerated, administer iron supplements on empty stomach -give with vitamin C to increase absorption -use z-track into deep muscle for parenteral injected; do not massage after
A nurse is caring for a client who has a major burn and is experiencing severe pain. Which of the following is an appropriate nursing intervention to manage this client's pain? A. Administer morphine sulfate IV via continuous infusion. B. Administer meperidine (Demerol) IM as needed. C. Administer acetaminophen (Tylenol) PO every 4 hr. D. Administer hydrocodone (Vicodin) PO every 6 hr.
A. Administer morphine sulfate IV via continuous infusion.
A nurse is conducting a well-child visit with a child who is scheduled to receive the recommended immunizations for 4- to 6-year-olds. Which of the following immunizations should the nurse administer? (Select all that apply.) A. Diphtheria, tetanus, pertussis (DTaP) B. Inactivated poliovirus (IPV) C. Measles, mumps, rubella (MMR) D. Pneumococcal (PCV) E. Haemophilus influenzae type b (Hib)
A. Diphtheria, tetanus, pertussis (DTaP) B. Inactivated poliovirus (IPV) C. Measles, mumps, rubella (MMR)
A nurse is assessing a child who has a rotavirus infection. Which of the following are expected findings? (Select all that apply.) A. Fever B. Vomiting C. Watery stools D. Bloody stools E. Confusion
A. Fever B. Vomiting C. Watery stools
A nurse is assessing a child. Which of the following are clinical manifestations of epiglottitis? (Select all that apply.) A. Hoarseness and difficulty speaking B. Difficulty swallowing C. Low-grade fever D. Drooling E. Dry, barking cough F. Stridor
A. Hoarseness and difficulty speaking B. Difficulty swallowing D. Drooling F. Stridor
A nurse is conducting a well-child visit with a child who is scheduled to receive the recommended immunizations for 11- to 12-year-olds. Which of the following immunizations should the nurse administer? (Select all that apply.) A. Trivalent inactivated influenza (TIV) B. Pneumococcal (PCV) C. Meningococcal (MCV4) D. Tetanus and diphtheria toxoids and pertussis (Tdap) E. Rotavirus (RV)
A. Trivalent inactivated influenza (TIV) C. Meningococcal (MCV4) D. Tetanus and diphtheria toxoids and pertussis (Tdap)
A nurse is teaching a child who has asthma how to use a peak flow meter. Which of the following should be included in the teaching? (Select all that apply.) A. Zero the meter before each use. B. Record the average of the attempts. C. Perform three attempts. D. Deliver a long, slow breath into the meter. E. Sit in a chair with fee
A. Zero the meter before each use. C. Perform three attempts
Which drug is usually the best choice for patient-controlled analgesia (PCA) for a child in the immediate postoperative period? a. Codeine b. Morphine c. Methadone d. Meperidine
ANS: B The most commonly prescribed medications for PCA are morphine, hydromorphone, and fentanyl. Parenteral use of codeine is not recommended. Methadone is not available in parenteral form in the United States. Meperidine is not used for continuous and extended pain relief.
Acetaminophen overdose antidote
Acetylcysteine
Aspirin overdose antidote
Activated charcoal
A nurse is caring for an infant who has a prescription for digoxin 25 mcg PO. The infant has an apical heart rate of 124/min. Which of the following actions should the nurse take? Administer 25 mcg as prescribed. Hold the medication until the next dose. Hold the medication and recheck the apical heart rate in 30 min. Administer 12.5 mcg of the medication.
Administer 25 mcg as prescribed. hold if <90
Glomerulonephritis lab value to be present
Antistreptolysin (ASO titer)
School aged child dx w/ asthma, reports chest pain. RN action
Auscultate breath sounds (1st action of nursing process)
Epiglottitis nursing interventions
Avoid throat culture or tongue blade, IV corticosteroids, droplet precautions for first 24 hours after IV antibiotics initiated.
A nurse is caring for a child in the postoperative period following a tonsillectomy. Which of the following is an appropriate action for the nurse to take? A. Encourage the child to blow her nose gently. B. Administer analgesics on a schedule. C. Offer orange juice. D. Position the child supine.
B. Administer analgesics on a schedule.
Transdermal fentanyl (Duragesic) is being used for an adolescent with cancer who is in hospice care. The adolescent has been comfortable for several hours but now complains of severe pain. The most appropriate nursing action is to: A. Administer meperidine (Demerol) intramuscularly (IM). B. Administer morphine sulfate immediate release (MSIR) intravenously (IV). C. Use a nonpharmacologic strategy. D. Place another fentanyl patch on the adolescent.
B. Administer morphine sulfate immediate release (MSIR) intravenously (IV).
A nurse is assessing an infant. Which of the following should the nurse recognize as clinical manifestations of heart failure? (Select all that apply.) A. Bradycardia B. Cool extremities C. Peripheral edema D. Increased urinary output E. Nasal flaring
B. Cool extremities C. Peripheral edema E. Nasal flaring
A child who has been receiving morphine intravenously will now start receiving it orally. The nurse should anticipate that, to achieve equianalgesia (equal analgesic effect), the oral dose will be: A. The same as the intravenous (IV) dose. B. Greater than the IV dose. C. One half of the IV dose. D. One fourth of the IV dose.
B. Greater than the IV dose.
A nurse is caring for a child. Which of the following are clinical manifestations of poststreptococcal glomerulonephritis (APSGN)? (Select all that apply.) A. Frothy urine B. Periorbital edema C. Ill appearance D. Decreased creatinine E. Hypertension
B. Periorbital edema C. Ill appearance E. Hypertension
A nurse is planning caring for a child who has asthma. Which of the following interventions should be included in the plan of care? (Select all that apply.) A. Perform chest percussion. B. Place the child in an upright position. C. Monitor oxygen saturation. D. Administer bronchodilators. E. Administer dornase alfa (Pulmozyme) daily.
B. Place the child in an upright position. C. Monitor oxygen saturation. D. Administer bronchodilators.
A nurse is assessing a 6-month-old infant. Which of the following reflexes should the infant exhibit? A. Moro B. Plantar grasp C. Stepping D. Tonic neck
B. Plantar grasp
A nurse is developing an in-service about viral and bacterial meningitis. The nurse should include that the introduction of which of the following immunizations decreased the incidence of bacterial meningitis in children? (Select all that apply.) A. Inactivated polio vaccine (IPV) B. Pneumococcal conjugate vaccine (PCV) C. Diphtheria and tetanus toxoids and acellular pertussis vaccine (DTaP) D. Haemophilus influenzae type B (Hib) vaccine E. Trivalent inactivated influenza vaccine (TIV)
B. Pneumococcal conjugate vaccine (PCV) D. Haemophilus influenzae type B (Hib) vaccine
A nurse is caring for a 10-year-old child who has acute glomerulonephritis (AGN). Which of the following findings should the nurse report to the provider? A. Serum BUN 8 mg/dL B. Serum creatinine 1.3 mg/dL C. Blood pressure 100/74 mm Hg D. Urine output 550 mL over 24 hr
B. Serum creatinine 1.3 mg/dL
What instruction should the nurse include when teaching parents of a child with CHF about digoxin administration at home?
Brush the child's teeth after administering digoxin, which comes as a sweetened liquid to enhance the taste
A nurse is providing teaching to the mother of an infant who is to start taking digoxin (Lanoxin). Which of the following instructions should the nurse include? A. "Do not offer your baby fluids after giving the medication." B. "Digoxin increases your baby's heart rate." C. "Give the correct dose of medication at regularly scheduled times." D. "If your baby vomits a dose, you should repeat the dose to ensure that he gets the correct amount."
C. "Give the correct dose of medication at regularly scheduled times."
A nurse is caring for a child who is in the postoperative period following a tonsillectomy. Which of the following is a clinical finding of postoperative bleeding? A. Hgb of 11.6 and Hct of 37% B. Inflamed and reddened throat C. Frequent swallowing and clearing of the throat D. Blood-tinged mucus
C. Frequent swallowing and clearing of the throat
A nurse is teaching the parent of a child who has asthma. Which of the following should be included in the teaching? Perform chest physiotherapy twice a day. Give montelukast before breakfast. Check peak expiratory flow rate at the same time each day. Administer fluticasone/salmeterol as needed for wheezing.
Check peak expiratory flow rate at the same time each day.
A nurse is teaching the parent of a child who has celiac disease. Which of the following grains can be included in the child's diet? Barley Corn Wheat Rye
Corn
A nurse is conducting a well-baby visit with a 4-month-old infant. Which of the following immunizations should the nurse administer to the infant? SATA A. MMR B. Polio C. Pneumococcal vaccine D. Varicella E. Rotavirus vaccine
Correct Answer: B, C, and E First MMR vaccine not given until 12-15 months. First varicella should not be given until minimum of 12 months.
A nurse is providing teaching to the parent of a child who has a new prescription for liquid oral iron supplements. Which of the following statements by the parent indicates an understanding of the teaching? A. "I should take my child to the emergency department if his stools become dark." B. "My child should avoid eating citrus fruits while taking the supplements." C. "I should give the iron with milk to help prevent an upset stomach." D. "My child should take the supplement through a straw."
D. "My child should take the supplement through a straw.
A nurse is teaching an adolescent about the appropriate use of his asthma medications. Which of the following should the client be instructed to take as needed before exercise? A. Fluticasone/salmeterol (Advair) B. Montelukast (Singulair) C. Prednisone (Deltasone) D. Albuterol (Proventil)
D. Albuterol (Proventil)
Immunizations given at 2 months of age:
DTaP, Rotavirus, IPV, Hib, PCV, Hep B
Diagnosing autism spectrum disorder
Delays in at least one of the following: Social interaction, social communication, imaginative play prior to age 3.
What to avoid after a tonsillectomy:
Discourage coughing, throat clearing, and nose blowing; no spicy foods, limit strenuous activity
A parent expresses concern to the nurse that her 18 month old may have autism. Which of the following characteristics described by the parent should the nurse report to the primary care provider? Easily distracted Dislikes being held Lack of coordination when running Frequent temper tantrums
Dislikes being held
Acute glomerulonephritis lab levels:
Elevated BUN, creatinine, positive ASO titer, proteinuria, hematuria
Epiglotitis prevention
HIB vaccine prevents
Immunization to prepare 4 months old for
Inactivated polio
Asthma what to report
Intercostal retractions
Testing for autism
MCHAT at 18 months to rule out autism.
PDA manifestations:
Murmur like a machine hum, wide PP, bounding pulses
Appendectomy post-op care what to report
Muscle rigidity
A nurse is caring for a child who is experiencing respiratory depression after an administration of morphine. Which of the following medications should the nurse plan to administer for this child? Flumazenil Diphenhydramine Naloxone Butorphanol
Naloxone
A nurse is caring for an infant who has heart failure. Which of the following is an appropriate action for the nurse to take? Provide stimulation every hour. Feed the infant every 1 to 1 & ½ hours. Perform daily weights. Maintain the infant in the supine position.
Perform daily weights.
nurses expected finding in Infant w/ heart failure
Peripheral edema (systemic venous congestion)
Important nursing considerations for epiglottis
Protect the airway DO NOT VISUALIZE
A nurse is providing discharge teaching to the parent of a school-age child who has cystic fibrosis. Which of the following should the nurse include in the teaching? Provide high protein and high caloric snacks. Administer pancreatic enzymes at bedtime. Perform chest percussion before each meal. Limit physical activity at school.
Provide high protein and high caloric snacks.
What should nurse do to minimize the traumatic experience of getting immunizations
Provide pacifier with sugar
Nutrition for acute glomerulonephritis:
RESTRICT SODIUM, POTASSIUM, and fluids; avoid added salt; provide small, frequent meals
Tonsillectomy care:
Rest, COOL fluids, warm salt-water gargles, ICE COLLAR, acetaminophen and codeine, clear liquids, avoid red-colored liquids (keep the throat moist)
Glomerulonephritis & is edematous. plan of care
Restrict sodium intake
Food choices for celiac disease.
Rice pudding
A nurse is reviewing the laboratory values for an infant who is receiving treatment for severe dehydration. Which of the following laboratory values indicates the effectiveness of the treatment? Serum potassium 2.9 mEq/L Serum sodium 140 mEq/L Urine specific gravity 1.035 BUN 25 mg/dL
Serum sodium 140 mEq/L
A nurse is assessing a client diagnosed with celiac disease. Which of the following is an expected finding? Steatorrhea Hypertonia Sunken abdomen Weight gain
Steatorrhea
How to get rooting reflex & expected ages
Stroke an infant's cheek or edge of mouth birth to 4 months
How to get Bakinski reflex & expected ages
Stroke the outer edge of the sole of the foot up toward the toes toes should fan upward and out birth to 1 year
Signs of severe dehydration
Sunken anterior fontanel No tearing with sunken eyeballs Oliguria/anuria
A nurse is caring for a toddler who has gastroenteritis and a stool culture that is positive for rotavirus. Which of the following assessment findings should the nurse address first? Tachycardia Tachypnea Hyperpyrexia Hypotension
Tachypnea
highest priority finding in 4mo with heart failure.
Three episodes of vomiting (vomiting may indicate digoxin toxicity)
to inspect after Tonsillectomy
Use flashlight to visualize the throat
A nurse is caring for a child who has suspected rotavirus and is scheduled to undergo a stool culture specimen collection. Which of the following nursing interventions should the nurse implement to maintain standard precautions? (Select all that apply) Wear gloves and gown during collection. Collect the child's stool specimen by using a potty hat. Remove the potty hat from the client's room for disposal. Place the specimen in a biohazard bag. Ask the child's parent to place the stool-smeared toilet tissue in the potty hat.
Wear gloves and gown during collection. Collect the child's stool specimen by using a potty hat. Place the specimen in a biohazard bag.
Diaper dermatitis. apply ____ to affected area
Zinc oxide
a nurse is caring for a child who is in skeletal traction. which of the following actions should the nurse take? (select all that apply) a. remove weights to reposition child b. assess child's position frequently c. assess pin sites every 4 hours d. ensure the weights are hanging freely e. ensure the rope's knot is in contact with the pulley
b. assess child's position frequently c. assess pin sites every 4 hours d. ensure the weights are hanging freely
A NURSE IS PERFORMING A PHYSICAL ASSESSMENT ON A 6 MONTH OLD. which of the following reflexes should the nurse expect to find at this age? a. stepping b. babinski c. extrusion d. moro
b. babinski present until the age of 1
A nurse is caring for an 18 year old adolescent who is going away to college. The adolescent will be living in the dorms. Which of the following is the most appropriate immunization to suggest that he receive? a. pneumococcal polysaccaride b. meningococcal polysaccaride c. influenza d. varicella
b. meningococcal polysaccaride
when should a child receive the RV (rotavirus vaccine)
by the age of 6 months
A nurse is assessing a child who has asthma. Which of the following are indications of deterioration in the child's respiratory status? (Select all that apply.) A. Oxygen saturation 95% B. Wheezing C. Retraction of sternal muscles D. Warm extremities E. Nasal flaring
B. Wheezing C. Retraction of sternal muscles E. Nasal flaring
acute glomerulonephritis is
accompanied by hematuria
a nurse is caring for an infant who has diaper dermatitis. what should be included in the plan of care?
allow buttocks to air dry apply zinc oxide ointment to the affected area
what is the desired outcome when taking digoxin?
allowing easier breathing by increasing cardiac output and decreasing venous pressure and edema. Increases urinary output
how to get moro reflex & expected ages
also known as startle reflex when head or trunk of infant fall backward-> infant arms and legs to symmetrically extend then abduct while fingers spread to make C shape Birth-4months
live virus immunizations
avoid for 3 months in children who have received passive immunity through immunoglobulin's
what is manifestation of moderate dehydration
cap refill 3 secs, dry mucous membranes, decreased tearing
characteristics of urine with Acute glomerulonephritis
cloudy and tea-colored
A nurse is caring for a 2 year old child with cystic fibrosis. The nurse is planning to take the child to the playroom. Which of the following activities would be the most appropriate for the child? a. cutting and gluing b. blowing soap bubbles c. riding a tricycle d. building block towers
d. building block towers
A nurse is caring for an 8 year old who has fractured his femur. The child is in skeletal traction. To assist with the child's developmental needs, which of the following would be an appropriate action for the nurse to take? a. allow the child to play video games daily b. take the child to the playroom daily, in the bed, maintaining traction c. assign roommates for the child who are of similar ages d. have the hospital tutor visit to assist the child with homework
d. have the hospital tutor visit to assist the child with homework
A nurse is working at an immunization clinic. Which of the following would be a contraindication to the pertussis immunization? a. History of fever of 101F after a previous immunization b. sibling who had an adverse reaction to pertussis immunization c. documented history of egg allergy d. known neurological or seizure disorder
d. known neurological or seizure disorder Other valid contraindications: fever greater than 105F or extreme lethargy following immunization
a nurse is teaching a group of parents about communicable diseases. Which of the following in the most appropriate method to prevent a communicable disease? a. handwashing b. avoiding persons with active disease c. covering your cough d. obtaining immunizations
d. obtaining immunizations
lack of apetite is a symptom of what toxicity
digoxin
The Moro reflex
exhibited by infants from birth-4 months.
what medication should be administered long term for asthma ?
fluticasone cromylon sodium montekulast
The tonic neck reflex
is exhibited by infants from birth-3 to 4 months.
The stepping reflex
is exhibited by infants from birth-4 weeks.
manifestation of Tylenol poisoning ?
jaundice
what is a manifestation of aspirin poising ?
oliguria & tinnitus
what medication should be used to treat an acute asthma attack?
proventil (albuterol)
type of feeding for a child who has had heart failure
provide small frequent feedings; helps conserve energy due to high metabolic rate
What should you check prior to administering Digoxin?
pulse
Epiglotitis treatment
racemic epinephrine, corticosteroids , IV fluids, antibiotics
highest priority after tonsillectomy
report continuous swallowing, it can indicate active bleeding which places the patient at risk for hemorrhage
when collecting a stool sample with possible rotavirus
should be placed in a biohazard bag
Position of bed for child with heart failure
the head of a bed should be elevated to 45 degrees in a child with heart failure to decrease cardiac demand
how to get Plantar Grasp & expected ages
touching the sole of infants foot-> the infants toes to curl downward Birth-8months
What should you give after to a patient receiving Digoxin?
water
what is manifestation of SEVERE dehydration ?
weight loss of 10%
how to get Palmar Grasp & expected ages
when place object in infants palm-the infant grasps the object Birth-3months
a decrease in tear production may be an indication of
worsening dehydration
