Missed ATI questions to review
A nurse is assessing a school-aged child after a ventriculoperitoneal (VP) shunt replacement. Which of the following findings indicates a complication of this procedure?
Abdominal distention A VP shunt allows excess cerebrospinal fluid from the ventricles to drain into the peritoneal cavity and be reabsorbed. Abdominal distention can indicate the presence of peritonitis due to the draining cerebral spinal fluid or a postoperative ileus.
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?
Call the poison control center. According to evidence-based practice, the nurse should instruct the parents to first call the poison control center, which will then identify what further actions the parents should take.
The nurse is providing teaching to the parent of a 4-year-old child who stutters. Which of the following statements by the parent indicates an understanding of the teaching? A. "I should ignore the stuttering and not interrupt her." B. "I should finish my child's sentence if she is stuck on a word." C. "I should reward my child when she doesn't stutter." D. "I should tell my child to slow down when she starts stuttering."
Correct Answer: A. "I should ignore the stuttering and not interrupt her." Stuttering is an expected part of speech development in the preschool years. As language skills improve, stuttering typically ceases by 5 years of age. Parents should be instructed not to focus on the stuttering so the behavior is not reinforced and does not become
The nurse is providing teaching to the parent of a 4-year-old child who stutters. Which of the following statements by the parent indicates an understanding of the teaching?
Correct Answer: A. "I should ignore the stuttering and not interrupt her." Stuttering is an expected part of speech development in the preschool years. As language skills improve, stuttering typically ceases by 5 years of age. Parents should be instructed not to focus on the stuttering so the behavior is not reinforced and does not become prolonged.
A nurse is assisting with discussing a nonstress test with a client who is at 39 weeks of gestation. Which of the following statements indicates an understanding of the information? A. "This test will assist in determining if my baby is okay by monitoring the heart rate." B. "This test will determine if chromosomal disorders are present." C. "This test will require me to take a medication that will prompt contractions." D. "This test will use sonar to determine how my baby is doing."
Correct Answer: A. "This test will assist in determining if my baby is okay by monitoring the heart rate." The nurse should instruct the client that a nonstress test will provide information that will evaluate fetal wellbeing by assessing the fetal heart rate and fetal movement.
A nurse is assessing a school-aged child after a ventriculoperitoneal (VP) shunt replacement. Which of the following findings indicates a complication of this procedure? A. Abdominal distention B. Unequal peripheral pulses C. Pinpoint pupils D. Frontal bossing
Correct Answer: A. Abdominal distention A VP shunt allows excess cerebrospinal fluid from the ventricles to drain into the peritoneal cavity and be reabsorbed. Abdominal distention can indicate the presence of peritonitis due to the draining cerebral spinal fluid or a postoperative ileus.
A nurse is providing teaching to the parent of a child who has cystic fibrosis and a prolapsed rectum. The nurse should identify that which of the following is a cause of this complication? A. Bulky stools B. Weakened rectal sphincter C. Elevated pancreatic enzymes D. Decreased intra-abdominal pressure
Correct Answer: A. Bulky stools The nurse should identify that bulky stools can cause a child who has cystic fibrosis to develop a prolapsed rectum. The nurse should implement interventions to help decrease the bulk of the child's stools.
A nurse is preparing to feed an infant who has a cleft lip and palate. Which of the following actions should the nurse plan to take?
Correct Answer: A. Burp the infant at least 2 to 3 times during the feeding Infants who have a cleft lip and palate will swallow an increased amount of air during a feeding due to a lack of separation between the oral and nasal cavities. Infants should be burped after every ounce of formula consumed.
A nurse is preparing to feed an infant who has a cleft lip and palate. Which of the following actions should the nurse plan to take? A. Burp the infant at least 2 to 3 times during the feeding B. Remove the nipple from the infant's mouth if swallowing becomes audible C. Stop the feeding if formula appears in the nasal cavity of the infant D. Discourage the parents from participating in the feeding prior to a surgical repair
Correct Answer: A. Burp the infant at least 2 to 3 times during the feeding Infants who have a cleft lip and palate will swallow an increased amount of air during a feeding due to a lack of separation between the oral and nasal cavities. Infants should be burped after every ounce of formula consumed.
A nurse is providing teaching to an adolescent who was recently diagnosed with type 1 diabetes mellitus. Which of the following insulin injection sites should the nurse recommend that the client use during basketball competitions? A. Hip B. Upper arm C. Thigh D. Lower leg
Correct Answer: A. Hip Vigorous exercise can enhance the absorption of injected insulin from an involved extremity. When participating in vigorous exercise that involves both the arms and legs, the client should use a hip as the insulin injection site.
A nurse is assessing a child who has bilateral pheochromocytoma. Which of the following findings should the nurse expect? A. Hypertension B. Abdominal obesity C. Bradycardia D. Loose stools
Correct Answer: A. Hypertension The nurse should expect a child who has pheochromocytoma to exhibit hypertension due to the increased production of catecholamines. Other manifestations include sweating, weight loss, and polyuria.
A nurse is preparing to administer routine immunizations to a 6-year-old child. In addition to the diphtheria, tetanus, and pertussis (DTaP) vaccine; the measles, mumps, and rubella (MMR) vaccine; and the varicella vaccine, which of the following immunizations should the nurse plan to administer? A. Inactivated poliovirus vaccine (IPV) B. Haemophilus influenzae type B vaccine (Hib) C. Pneumococcal conjugate vaccine (PCV) D. Hepatitis B vaccine (HBV)
Correct Answer: A. Inactivated poliovirus vaccine (IPV) The nurse should plan to administer the fourth dose of the inactivated poliovirus vaccine between 4 and 6 years of age. The first 3 doses are administered between 2 and 18 months of age.
A nurse is caring for the family of a preschooler who has a terminal illness. The nurse should teach the family to expect the preschooler to have which of the following concepts of death? A. People can come back to life after they die. B. Death eventually occurs for all people. C. Death is a scary monster that causes people to die. D. People are unable to be anything but alive.
Correct Answer: A. People can come back to life after they die. A preschooler typically views death as temporary and interchangeable with life.
A nurse is planning care for a 4-year-old child who has nephrotic syndrome. Which of the following actions should the nurse take? A. Provide thorough skin care B. Test for blood type and cross-match C. Allow ample hydrating fluids D. Maintain a low-carbohydrate diet
Correct Answer: A. Provide thorough skin care The nurse should provide thorough skin care for this child who has nephrotic syndrome. Skin care is especially important due to edema and the risk of infection.
A nurse is teaching an adolescent about managing asthma and using a peak expiratory flow meter. Which of the following statements by the client demonstrates an understanding of the teaching? A. "I will use my peak flow meter whenever I feel short of breath." B. "I will continue to take my medication when my peak flow rate is in the green zone." C. "I need to use the average of 3 readings when I measure my flow rate." D. "My asthma is being controlled if my flow rate is in the yellow zone."
Correct Answer: B. "I will continue to take my medication when my peak flow rate is in the green zone."
A nurse is reviewing the laboratory results of a child who has experienced diarrhea for the past 24 hr. Which of the following values for urine specific gravity should the nurse expect? A. 1.010 B. 1.035 C. 1.020 D. 1.005
Correct Answer: B. 1.035 1.035 is a concentrated specific gravity, which is an expected value for a child who is dehydrated; therefore, this is an expected urine specific gravity for a child who has experienced diarrhea for 24 hours.
A nurse is assessing an infant who has acute gastroenteritis. Which of the following findings should the nurse identify as the priority? A. Decreased skin turgor B. Capillary refill 5 seconds C. Heart rate 150/min D. Dry mucous membranes
Correct Answer: B. Capillary refill 5 seconds When using the urgent vs nonurgent approach to client care, the nurse should identify that the priority finding is a capillary refill of 5 seconds. A capillary refill above 4 seconds is an indication of severe dehydration and requires immediate intervention to prevent progression to hypovolemic shock.
A nurse is providing discharge teaching to the guardian of an adolescent who is postoperative following a tonsillectomy. Which of the following manifestations should the guardian report to the provider? A. Nasal secretions containing dark brown blood B. Constant clearing of the throat C. Unpleasant odor from the oral cavity D. Temperature of 37.7°C (99.8°F) at 48 hr postoperative
Correct Answer: B. Constant clearing of the throat A manifestation of hemorrhage following a tonsillectomy is the constant clearing of blood that is draining in the back of the throat. Therefore, it should be reported to the provider if the adolescent begins constantly clearing the throat following a tonsillectomy.
A nurse is assessing a 9-month-old infant. Which of the following findings should the nurse report to the provider as a possible developmental delay? A. Grasping a small object with just the thumb and index finger B. Dropping a cube when passing from 1 hand to the other C. Falling from a standing position to sitting D. Losing balance when leaning sideways while sitting
Correct Answer: B. Dropping a cube when passing from 1 hand to the other The ability to pass a cube from a hand to the other is a fine motor skill expected of a 7-month-old infant. Therefore, the nurse should identify the 9-month-old infant's inability to perform this task as a possible developmental delay and should report this finding to the provider.
A nurse is providing teaching to the parent of a school-aged child who has pediculosis. Which of the following instructions should the nurse include? A. Machine-wash clothing in cold water B. Dry clothing in a hot dryer for at least 20 min C. Soak combs and brushes for 5 min in boiling water D. Seal nonwashable items in a bag for 7 days
Correct Answer: B. Dry clothing in a hot dryer for at least 20 min The nurse should instruct the parent to dry the child's clothing in a hot dryer for at least 20 minutes.
A nurse is reviewing the laboratory report of a toddler who is receiving chemotherapy for leukemia. Which of the following laboratory values should the nurse report to the provider? A. Platelets 150,000/mm^3 B. Hgb 6 g/dL C. WBC 6,000/mm^3 D. Potassium 4.5 mEq/L
Correct Answer: B. Hgb 6 g/dL This hemoglobin level is below the expected reference range and is indicative of anemia; therefore, the nurse should report this finding to the provider.
A nurse is caring for a toddler who has gastroenteritis caused by Salmonella. Which of the following is the priority action for the nurse? A. Weigh the child B. Initiate contact precautions C. Establish a skin care routine D. Obtain a recent food history
Correct Answer: B. Initiate contact precautions Salmonella is a type of bacteria that is transmitted via contaminated feces, making contact precautions essential for preventing transmission. This client is at greatest risk for transmission of Salmonella to others; therefore, contact precautions are the nurse's priority.
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 recommend which of the following immunizations prior to moving into a campus dormitory? A. Pneumococcal polysaccharide B. Meningococcal polysaccharide C. Rotavirus D. Herpes zoster
Correct Answer: B. Meningococcal polysaccharide The meningococcal polysaccharide immunization is used to prevent infection by certain groups of meningococcal bacteria. Meningococcal infection can cause life-threatening illnesses, such as meningococcal meningitis (which affects the brain) and meningococcemia (which affects the blood). Both of these conditions can be fatal. College freshmen, particularly those who live in dormitories, are at an increased risk for meningococcal disease relative to other persons their age. Therefore, the Centers for Disease Control and Prevention issued a recommendation that all incoming college students receive the meningococcal immunization.
A nurse is assessing a child who has a ventricular septal defect. Which of the following findings should the nurse expect? A. Diastolic murmur B. Murmur at the left sternal border C. Cyanosis that increases with crying D. Widened pulse pressure
Correct Answer: B. Murmur at the left sternal border A ventricular septal defect (a hole in the septal wall between the ventricles) is an acyanotic heart defect. A systolic murmur can be heard best at the lower left sternal border. The sound is transmitted in the direction of blood flow, so any backflow of blood from the left to the right ventricle through the septal defect is best heard in this area.
A nurse is caring for a child who has an exacerbation of cystic fibrosis. Which of the following laboratory findings should the nurse report to the provider immediately? A. Blood glucose 140 mg/dL B. Oxygen saturation 85% C. RBC 3.2 million/uL D. Serum sodium 156 mEq/L
Correct Answer: B. Oxygen saturation 85% The nurse should apply the ABC priority-setting framework, which emphasizes the basic core of human functioning: having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these areas can indicate a threat to life and is the nurse's priority concern. When applying the ABC priority-setting framework, airway is always the highest priority because the airway must be clear for oxygen exchange to occur. Breathing is the second-highest priority because adequate ventilatory effort is essential in order for oxygen exchange to occur. Circulation is the third-highest priority because the delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them. Therefore, the nurse should report this finding to the provider immediately.
A nurse is caring for an adolescent following a lumbar puncture. Which of the following actions should the nurse take? A. Initiate NPO status for the adolescent B. Place the adolescent in a supine position C. Place a moist, warm pack on the adolescent's lower back D. Apply a eutectic mixture of local anesthetics (EMLA) to the adolescent's puncture site
Correct Answer: B. Place the adolescent in a supine position The nurse should place the adolescent in a supine position for 30 minutes to 1 hour following a lumbar puncture to decrease the risk of a post-dural puncture headache.
A nurse is assessing an adolescent who has appendicitis. Which of the following manifestations should the nurse expect? x A. Upper right quadrant abdominal pain ✔ B. Rigid abdomen C. Hyperactive bowel sounds D. Bradycardia
Correct Answer: B. Rigid abdomen A rigid abdomen is an expected manifestation of appendicitis.
A nurse is caring for a child who has a ruptured appendix. Which of the following positions should the nurse encourage the child to maintain?
Correct Answer: B. Semi-Fowler's Maintaining a semi-Fowler's position promotes adequate ventilation. Flexing the knees slightly will likely be the most comfortable position for the child. Additionally, this promotes drainage of the cecum downward into the pelvis instead of upward toward the lungs.
A nurse on a pediatric oncology unit is helping the parents of a child who is terminally ill to prepare for the impending loss of their child. Which of the following statements should the nurse make?
Correct Answer: C. "Would you like assistance in planning where your child will die?" The nurse should inform the parents that they can choose to keep the child in a hospital setting or take the child home to die. The nurse should be aware that active participation in planning for the location of the child's death promotes positive bereavement outcomes. The nurse should provide assistance to the parents in making and implementing this plan.
A nurse in the emergency department is reviewing laboratory results for several children who have manifestations of influenza. Which of the following children should the nurse report to the provider immediately? A. A school-age child with a urine specific gravity of 1.035 B. A toddler with a BUN of 25 mg/dL and a creatinine of 0.5 mg/dL C. An infant with a WBC count of 24,000/mm3 D. An adolescent with a positive beta human chorionic gonadotropin test
Correct Answer: C. An infant with a WBC count of 24,000/mm3 The nurse should apply the safety and risk-reduction priority-setting framework. This framework assigns priority to the factor or situation posing the greatest safety risk to the client. When there are several risks to client safety, the one posing the greatest threat is the highest priority. The nurse should use Maslow's Hierarchy of Needs, the ABC priority-setting framework, and/or nursing knowledge to identify which risk poses the greatest threat to the client. This WBC count is high and indicates infection and possibly sepsis, which poses the greatest risk. The provider must initiate blood, urine, and spinal fluid cultures and begin antimicrobial therapy.
A nurse is providing dietary teaching to the parent of a toddler who has phenylketonuria. Which of the following foods should the nurse recommend? A. Whole milk B. Ground beef C. Cooked carrots D. Eggs
Correct Answer: C. Cooked carrots The nurse should instruct the parent to offer the toddler foods that are low in protein such as cooked carrots and fruits.
A nurse is assessing an 18-month-old infant who is postoperative. Which of the following pain scales should the nurse use? A. FACES B. CRIES C. FLACC D. PIPP
Correct Answer: C. FLACC The nurse should use the FLACC pain scale to monitor the infant for pain. The FLACC scale monitors facial expression, leg movement, activity, cry, and consolability in children 2 months to 7 years of age.
A nurse is providing teaching to the parent of a toddler who has bacterial conjunctivitis. Which of the following instructions should the nurse include? A. Clean secretions from the infected eye by wiping from the outer canthus toward the inner canthus and upward B. Keep the infected eye covered with warm compresses for the first 24 to 48 hr C. Notify the provider immediately if the sclera becomes inflamed D. Apply pressure to the outer canthus of the eye for 1 min after administering the eye drops
Correct Answer: C. Notify the provider immediately if the sclera becomes inflamed Although the conjunctiva becomes inflamed during this infection, the sclera should remain clear and white. If the sclera becomes inflamed, it can indicate the presence of a serious conjunctival infection, and the child should be assessed immediately by an ophthalmologist.
A nurse is planning care for an infant with an unrepaired myelomeningocele. Which of the following actions should the nurse take? A. Fasten the diaper loosely B. Cleanse the meningeal sac with povidone-iodine daily C. Palpate the abdomen for bladder distension D. Cover the sac with a dry, sterile gauze dressing
Correct Answer: C. Palpate the abdomen for bladder distension A neurogenic bladder is a common complication of a myelomeningocele. Even if the infant is having wet diapers, the nurse should assess for bladder distension due to the possibility of incomplete emptying of the bladder.
A nurse is caring for an infant who is preoperative for the treatment of an intact myelomeningocele sac. In which of the following positions should the nurse place the infant? A. Side-lying B. Supine C. Prone D. Semi-Fowler's Graded Response:
Correct Answer: C. Prone When providing preoperative care for an infant who has a myelomeningocele, the nurse should maintain the infant in a prone position. This position reduces pressure and the risk of trauma to the sac.
A nurse is assessing a school-age child who reports horseback riding 3 times per week and has injuries reportedly related to a fall from a horse. Which of the following findings should the nurse investigate further as an indication of child maltreatment? A. Bruising of the right elbow B. Dislocated left shoulder revealed by X-ray C. Thin, frail extremities D. Abrasions on both wrists
Correct Answer: C. Thin, frail extremities The nurse should identify that thin, frail extremities are related to malnourishment and can indicate child maltreatment. The nurse should investigate this finding further and report the results to the provider.
A nurse is providing teaching to a 12-year-old client who is recovering from an acute episode of hemophilia A. Which of the following statements should the nurse include in the teaching? A. "Have your parent stretch and move your legs for you." B. "Apply heat to joints that become painful, stiff, and swollen." C. "Take aspirin at the first sign of a headache." D. "You will be able to participate in physical exercises."
Correct Answer: D. "You will be able to participate in physical exercises." Physical exercise is important for the maintenance of joint mobility and muscle strengthening. Participation in non-contact sports and the use of protective equipment such as knee pads are encouraged, although high-impact athletic activities such as karate should be avoided.
A nurse is teaching the parents of a toddler who had an anaphylactic reaction to peanut butter about administering injectable epinephrine. Which of the following instructions should the nurse include?
Correct Answer: D. "You will need to increase the dosage as your child gains weight." Epinephrine is a weight-based medication that is available in dosages of 0.15 mg and 0.3 mg. As the child grows, it will be necessary to change the epinephrine dosage that is administered.
A nurse is creating a plan of care for a 6-month-old infant who requires continuous pulse oximetry monitoring. Which of the following interventions should the nurse include? A. Reposition the sensor to a new site once every 24 hr B. Secure the oximetry sensor to the infant's wrist C. Apply conduction gel to the skin before attaching the sensor D. Cover the oximetry sensor with clothing
Correct Answer: D. Cover the oximetry sensor with clothing The nurse should cover the sensor with clothing to prevent outside light from causing an altered or false reading.
A nurse is planning to use guided imagery for an early school-aged child who continues to have mild discomfort following the administration of an analgesic. Which of the following techniques should the nurse plan to use? A. Give the child a kaleidoscope and ask the child to find different designs B. Encourage the child to take a deep breath and let the body go limp on the exhale C. Teach the child to picture a stop sign whenever the pain begins D. Encourage the child to focus on a recent pleasurable experience
Correct Answer: D. Encourage the child to focus on a recent pleasurable experience The nurse should encourage the child to focus on a recent pleasurable experience such as a trip to the zoo, when using the nonpharmacological technique of guided imagery. This technique encourages the child to focus on the pleasurable experience rather than the sensation of pain. The technique can also be combined with relaxation and breathing techniques.
A nurse is caring for a school-aged child who has acute post-streptococcal glomerulonephritis. Which of the following manifestations should the nurse expect? A. Hypotension B. Elevated serum lipid levels C. Decreased serum potassium levels D. Hematuria
Correct Answer: D. Hematuria Hematuria can be detected visually in clients who have acute post-streptococcal glomerulonephritis.
A nurse is caring for a child who has tetralogy of Fallot. Which of the following laboratory values should the nurse expect to find? A. Platelet count of 20,000/mm^3 B. WBC 4,000/mm^3 C. Thyroid stimulating hormone 7.0 microunits/mL D. RBC 6.8 million/uL
Correct Answer: D. RBC 6.8 million/uL A child who has tetralogy of Fallot experiences cyanosis; therefore, the body responds by increasing RBC production (polycythemia) in an attempt to supply oxygen to all body parts.
A nurse is teaching a group of parents of toddlers about measures to reduce the risk of choking. Which of the following foods increase the risk of choking in toddlers? (Select all that apply.) A. Hot dogs B. Grapes C. Bagels D. Marshmallows E. Graham crackers
Correct Answers: A. Hot dogs B. Grapes C. Bagels D. Marshmallows Foods that are shaped like a tube, such as hot dogs and grapes, place toddlers at risk for choking because they can completely block the throat when swallowed whole due to their shape and solidity. Foods that are hard to chew, such as bagels and marshmallows, place toddlers at risk for choking; if swallowed before they are adequately chewed, they can block the airway.
A nurse is conducting a health assessment for a 24-month-old toddler at the local health department. The nurse should expect which of the following findings? (Select all that apply.) A. 8 deciduous teeth B. Ability to build a tower of 6 blocks C. Vocabulary of 10-20 words D. Slightly bowed or curved leg appearance E. Head circumference greater than chest circumference
Correct Answers: B. Ability to build a tower of 6 blocks D. Slightly bowed or curved leg appearance The nurse should expect a 24-month-old toddler to be able to stack a short tower of 6 or 7 blocks. Additionally, a 24-month-old toddler will have a "pot-bellied" appearance; the legs should be slightly bowed to support the weight of the comparatively large trunk.
A nurse is planning care for an infant who has heart failure. Which of the following interventions should the nurse include in the plan to meet the nutritional needs of the infant? (Select all that apply.) A. Offer the infant a feeding every 2 hr B. Allow 30 min to complete each feeding C. Gradually increase the caloric density of the formula D. Position the infant semi-upright during feedings E. Provide gavage feeding if respiratory rate exceeds 80/min
Correct Answers: B. Allow 30 min to complete each feeding C. Gradually increase the caloric density of the formula D. Position the infant semi-upright during feedings E. Provide gavage feeding if respiratory rate exceeds 80/min The nurse should allow 30 minutes for each feeding. This length of feeding allows adequate intake without causing the infant to get overly fatigued or to lose needed rest time before the next feeding. The nurse should plan to provide the infant with a formula that has increased caloric density. An infant who has heart failure has an increased metabolic rate due to impaired cardiac function. Adding expressed breast milk or enteral nutrition formula or oil to the formula provides the infant with increased calories in a decreased volume of feeding. The nurse should gradually increase the caloric density of the feeding by 2 kcal/oz/day to promote infant tolerance and decrease the risk of diarrhea. The nurse should plan to hold the infant in a semi-upright position during feedings to promote maximum chest expansion and decrease the risk of respiratory distress. The nurse should plan to withhold oral feedings and provide gavage feedings if the infant shows indications of stress or fatigue. An infant who has a respiratory rate of 80/min to 100/min has tachypnea, which is an indicator of infant stress.
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?
Cow's milk According to evidence-based practice, the nurse should instruct the parent that cow's milk is the most common food allergy in children. Some children are sensitive to the protein, called casein, found in cow's milk. They have difficulty metabolizing the casein and are, therefore, allergic to cow's milk.
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?
Ensure the child's dietary intake of calcium and iron is adequate. A child who has an elevated blood lead level should have an adequate intake of calcium and iron to reduce the absorption and effects of the lead. Dietary recommendations should include milk as a good source of calcium.
A nurse is caring for an infant following surgical repair of a cleft lip and palate. Which of the following actions should the nurse take?
Suction the infant gently with a bulb syringe PRN. The nurse should gently suction the infant's mouth with a bulb syringe to maintain a patent airway.
A nurse in an emergency department is assessing a school-age child who is experiencing an acute asthma exacerbation. Which of the following findings is the priority for the nurse to report to the provider?
Sudden decrease in wheezing The nurse should apply the urgent versus nonurgent priority setting framework. Using this framework, the nurse should consider urgent needs the priority need because they pose a larger risk to the client. A sudden decrease in wheezing can be an indication that the child is experiencing decreased air movement and should be reported to the provider. The nurse might also need to use Maslow's hierarchy of needs, the ABC priority setting framework, or nursing knowledge to identify which finding is the most urgent. A sudden decrease in wheezing (silent chest) indicates ventilator failure and an imminent respiratory arrest.
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?
Supine The client is placed in the supine position, with the client's legs in a frog position.
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?
"I lock my medications in the medicine cabinet." Locking up medications and other potential poisons prevents access. Toddlers have improved gross and fine motor skills that allow for further exploration of the environment and possible access to hazardous substances.
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?
"Injury by a corrosive liquid is more extensive than by a corrosive solid." The coating action of liquids permits larger areas of contact with tissues and results in more extensive injury.
A nurse is providing teaching to the parent of a 2-year-old toddler about nutrition. Which of the following statements by the parent indicates an understanding of the teaching?
"My child should consume 1,000 calories per day." Toddlers who are 2 years old should consume 1,000 calories daily.
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?
"The PICC line will last several weeks with proper care." PICC lines are the preferred venous access device for short to moderate term IV therapy. They can remain in place for long periods with proper care.
A nurse is assisting with discussing a nonstress test with a client who is at 39 weeks of gestation. Which of the following statements indicates an understanding of the information?
"This test will assist in determining if my baby is okay by monitoring the heart rate." The nurse should instruct the client that a nonstress test will provide information that will evaluate fetal wellbeing by assessing the fetal heart rate and fetal movement.
A nurse is teaching a parent of a 12-month-old infant about development during the toddler years. Which of the following statements should the nurse include?
"Your child should be able to scribble spontaneously using a crayon at the age of 15 months." The nurse should teach the parent that at the age of 15 months, the toddler should be able to scribble spontaneously, and at the age of 18 months, the toddler should be able to make strokes imitatively.
A nurse is reviewing the laboratory results of a child who has experienced diarrhea for the past 24 hr. Which of the following values for urine specific gravity should the nurse expect?
1.035 1.035 is a concentrated specific gravity, which is an expected value for a child who is dehydrated; therefore, this is an expected urine specific gravity for a child who has experienced diarrhea for 24 hr.
A nurse is preparing to assess a 3-month-old infant during a well-child visit. Which of the following observations should the nurse expect?
Correct Answer: A. The infant looks at his hands Infants usually start to look at their hands while lying down or sitting between 12 to 20 weeks of age. Convergence on near objects is usually well established by 3 months of age.
A nurse on a pediatric unit is reviewing the health record of a child 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?
Frequent hospitalizations Children who experience multiple and frequent hospitalizations are at an increased risk for stress-related reactions to hospitalization.
A nurse is preparing to administer a liquid medication to an infant. Which of the following actions should the nurse take?
Give the medication at the side of the infant's mouth. When administering medications to an infant, a needleless oral syringe or medicine dropper is placed in the side of the mouth (buccal cavity alongside the tongue) to prevent gagging and aspiration.
A nurse is providing teaching to an adolescent who was recently diagnosed with type 1 diabetes mellitus. Which of the following insulin injection sites should the nurse recommend that the client use during basketball competitions?
Correct Answer: A. Hip Vigorous exercise can enhance the absorption of injected insulin from an involved extremity. When participating in vigorous exercise that involves both the arms and legs, the client should use a hip as the insulin injection site
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?
Adult tetanus booster (Td) Td is recommended for wound prophylaxis in children ages 7 years and older. Td is also recommended every 10 years after 18 years of age.
A nurse is caring for a child who has a possible intussusception. The parents of the child ask the nurse how the diagnosis is made. Which of the following responses should the nurse make?
An abdominal ultrasound will confirm the pocket in the intestine." Intussusception is the invasion of one part of the intestine into the other, creating a pocket. The presence of an intussusception is confirmed by an abdominal x-ray, ultrasound, or CT scan.
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?
Birth weight is tripled The birth weight should triple by 12 months of age. By 30 months of age, the birth weight should be quadrupled.
A nurse is assessing a child who is receiving IV chemotherapy. Assessment findings include extravasation of the tissues surrounding the IV insertion site. In which order should the nurse take the following actions? (Move the steps into the box on the right, placing them in the order of performance. Use all the steps.)
Correct Answer: Stop the infusion Elevate the extremity Notify the provider Remove the IV line Step 1: Extravasation is the infusion of vesicant solutions or medications into surrounding tissues. After observing extravasation, the nurse should first stop the infusion. Step 2: Then elevate the extremity. Step 3: The nurse should notify the provider. Step 4: Remove the IV line. Treatment of extravasation varies according to the vesicant and might involve the infusion of an antidote through the IV line into the tissues. Therefore, the IV line is not removed until the provider's prescriptions have been initiated.
A nurse is teaching the parents of an infant about treatment options for profound sensorineural hearing loss. The nurse should include which of the following pieces of information about the function of cochlear implants? A. They provide direct stimulation of auditory nerve fiber. B. They conduct sound waves through the mastoid bone to the cochlea. C. They process digital sound to amplify several sound frequencies. D. They convert vibrations in the ear's structures to electrical signals.
Correct Answer: A. They provide direct stimulation of auditory nerve fiber. Cochlear implants work by directly stimulating nerve fibers in the cochlea.
A nurse in an emergency department is caring for a toddler who is in acute respiratory distress. Which of the following findings should alert the nurse to the possibility of epiglottitis?
Drooling Epiglottitis is a disorder caused by an inflammation of the epiglottis. It results in rapid swelling of the epiglottis, which can obstruct breathing. Drooling is common finding due to the toddler's inability to swallow saliva.
A nurse is caring for a child who is in skeletal traction. Which of the following actions is the nurse's priority?
Encourage the child to use an incentive spirometer. The nurse should apply the ABC priority-setting framework. This framework emphasizes the basic core of human functioning - having an open airway, being able to breathe in adequate amounts of oxygen, and circulating oxygen to the body's organs via the blood. An alteration in any of these can indicate a threat to life, and is therefore the nurse's priority concern. When applying the ABC priority setting framework, airway is always the highest priority because the airway must be clear and open for oxygen exchange to occur. Breathing is the second highest priority in the ABC priority setting framework because adequate ventilatory effort is essential in order for oxygen exchange to occur. Encouraging the child to use an incentive spirometer will assist the child in adequate oxygenation and is the priority nursing action. Circulation is the third highest priority in the ABC priority setting framework because delivery of oxygen to critical organs only occurs if the heart and blood vessels are capable of efficiently carrying oxygen to them.
A nurse is preparing to administer recommended highlight immunizations to a 2-month-old infant. Which of the following immunizations should the nurse plan to administer?
Haemophilus influenzae type B (Hib) and inactivated polio virus (IPV) The recommended immunizations for a 2-month-old infant include Hib and IPV. The Hib immunization series consists of 3 to 4 doses, depending on the immunization used, and at a minimum is administered at the ages of 2 months, 4 months, and 12 to 15 months. The IPV immunization series consists of 4 doses and is administered at the ages of 2 months, 4 months, 6 to 18 months, and 4 to 6 years.
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?
Head lags when pulled from a lying to a sitting position At the age of 5 months, the infant should have no head lag when pulled to a sitting position; therefore, the nurse should report this finding to the provider.
A nurse is teaching an adolescent who has asthma about how to use a peak expiratory flow meter (PEFM). Which of the following responses by the adolescent indicates an understanding of the teaching?
I will record the highest reading of three attempts." Once the client establishes a personal best, she should routinely check the PEFM by performing three attempts and recording the highest reading of the three.
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?
Inability to vocalize vowel sounds The infant should begin vocalizing vowel sounds at the age of 7 months, and by the age of 10 months, be able to say at least one word.
A nurse is providing discharge teaching to the parents of a child who has nephrotic syndrome. Which of the following instructions should the nurse include in the teaching?
Keep the child away from people who have an infection. Children who have nephrotic syndrome are at increased risk for infection and should avoid contact with people who have infections.
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?
Legs remain crossed and extended when supineLegs crossed and extended when supine is an unexpected finding and requires further assessment. At 6 months of age, the legs flex at the knees when the infant is supine. Crossed and extended legs when supine is a finding associated with cerebral palsy.
A nurse is planning care for an adolescent who has sickle cell anemia and is experiencing a vaso-occlusive crisis. Which of the following interventions should the nurse include in the plan?
Maintain the child on bed rest. The nurse should maintain bed rest for the child who is experiencing a vaso-occlusive crisis to minimize energy expenditure and avoid additional oxygen needs.
A nurse in a pediatric clinic is assessing a toddler at a well-child visit. Which of the following actions should the nurse take?
Minimize physical contact with the child initially. The nurse should initially minimize physical contact with the toddler, and then progress from the least traumatic to the most traumatic procedures.
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.)
Observing the parents' actions when feeding the child is correct. Inappropriate feeding techniques and meal patterns provided by parents can contribute to a child's growth failure. Maintaining a detailed record of food and fluid intake is correct. A nutritional goal for the child who has suspected FTT is to correct nutritional deficiencies, which can be identified by recording all food and fluid intake.
A nurse is caring for an 8-year-old child who has acute glomerulonephritis. Which of the following findings should the nurse expect?
Periorbital edema Periorbital edema is an expected finding in a child who has glomerulonephritis.
A nurse is reviewing the laboratory report of a 2-year-old child who has diarrhea and has been vomiting for 24 hr. Which of the following findings should the nurse report to the provider?
Potassium 2.5 mEq/L A potassium level of 2.5 mEq/L indicates hypokalemia, which can cause arrhythmias or even cardiac arrest; therefore, the nurse should report this finding to the provider.
A nurse is caring for a school-aged child who had an arm cast applied 8 hours ago. Which of the following findings should alert the nurse to a complication related to the casting?
The child reports tightness at the wrist The nurse should monitor the casted extremity to ensure the swelling does not increase and cause the cast to become too tight, which can result in impaired circulation. If this occurs, the child is at risk for compartment syndrome.
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?
Rock the child in long rhythmic movements. The nurse can implement relaxation strategies by sitting with the child in a well-supported position such as against the chest, and then rocking or swaying back and forth in long, wide movements.
A nurse is caring for a 6-week-old infant following a pyloromyotomy. Which of the following forms of feeding should the nurse anticipate for the infant 6 hr after the procedure?
Small, frequent bottle feedings of electrolyte solution Feedings begin 4 to 6 hr after the surgical procedure. The nurse should anticipate feeding the infant small, frequent increments of an electrolyte solution or sterile water.
A nurse is caring for a school-aged child who had an arm cast applied 8 hours ago. Which of the following findings should alert the nurse to a complication related to the casting? A. The child reports a pain level of 5 on a scale of 0 to 10 B. The child's hands are cool bilaterally C. The child reports tightness at the wrist D. The child's grasp is weak
The child reports tightness at the wrist The nurse should monitor the casted extremity to ensure the swelling does not increase and cause the cast to become too tight, which can result in impaired circulation. If this occurs, the child is at risk for compartment syndrome.
A nurse in a provider's office enters an examination room to assess an 8-month-old infant for the first time. Which of the following reactions by the infant should the nurse expect?
The infant turns away when the nurse approaches. The nurse should expect an 8-month-old infant to have a heightened fear of strangers. The infant is expected to cling to her parent and turn away when approached by a stranger.
A nurse is caring for a 15-month-old client who requires droplet precautions. Which of the following actions should the nurse take?
The nurse should wear a mask within 3 to 6 feet of the toddler to prevent the transmission of infections that are spread via large-droplet particles expelled in the air.
A nurse is caring for a child who has tetralogy of Fallot. Which of the following laboratory values should the nurse expect to find?
This hormone level is above the expected reference range. A child who has tetralogy of Fallot will not have changes in thyroid function levels.
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?
Wash and dry the infant's genitalia and perineum thoroughly. This is the method used to obtain a routine urine specimen of any sort in a child who is not toilet trained. The skin should be washed and dried to promote application of the adhesive of the collection device.
A nurse is caring for a 15-month-old toddler who requires droplet precautions. Which of the following actions should the nurse take?
Wear a mask when assisting the toddler with meals. The nurse should wear a mask when within 3 to 6 feet of the toddler to prevent the transmission of infections that are spread via large droplet particles expelled in the air.