Passpoint: Preschooler

The nurse has just administered a drug to a child. Which organ is most responsible for drug excretion in children? Lungs Kidneys Heart Liver

Kidneys The kidneys are most responsible for drug excretion in children. Less commonly, some drugs may be excreted via the lungs or liver. Drugs are never excreted by the heart in children or adults.

A mother of a 5-year-old child who was admitted to the hospital has a Protection from Abuse order for the child against his father. A copy of the order is kept on the pediatric medical surgical unit where the child is being treated. The order prohibits the father from having any contact with the child. One night, the father approaches the nurse at the nurses' station, politely but insistently demanding to see his child, and refusing to leave until he does so. What should the nurse do first? Firmly tell the father he must leave. Notify hospital security or the local authorities. Notify the nurse-manager. Notify the nursing coordinator on duty.

Notify hospital security or the local authorities. The Protection from Abuse order legally prohibits the father from seeing the child. In this situation, the nurse should notify hospital security or the local authorities of this attempt to breach the order, and allow them to escort the father out of the building. The father could be jailed or fined if he violates the order. The nurse shouldn't argue or continue explaining to the father that he must leave because it could place the nurse and the child at risk if the father becomes angry or agitated. The nursing coordinator and nurse-manager should be notified of the incident; the nurse's first priority, however, should be contacting security or the authorities.

A child with leukemia has just completed a course of methotrexate therapy. How soon should the nurse expect to see signs of bone marrow depression in this client? Within 2 weeks After induction therapy is completed Within 1 month Within hours

Within 2 weeks Bone marrow depression is most likely to occur 10 days after methotrexate is administered.

A 3-year-old child with Down syndrome, admitted to the pediatric unit with asthma, does not enunciate words well and holds on to furniture when walking. What question would be appropriate for the nurse to ask the parent? "How long has your child has been like this?" "How does your child's condition today differ from their normal condition?" "Is your child able to walk without holding on to furniture?" "Does your child always drool?"

"How does your child's condition today differ from their normal condition?" The nurse should evaluate the condition of the 3-year-old child with Down syndrome and asthma by asking the parent to compare it to the child's normal behavior. Asking how long the child has been like this may be interpreted poorly by the caregiver. The nurse should focus on what the child can do—not on what he cannot do—to preserve the family's self-esteem. Focusing on negative aspects of the child's behavior is inappropriate.

A previously toilet-trained 4-year-old child begins wetting the bed after being hospitalized. Which statement should a nurse make to the parents? "It is normal for a child to start wetting the bed again when hospitalized." "Try not to worry. We can just cut back on fluids at night." "Your child must not have been fully potty trained." "It is not uncommon for 4-year-olds to still have accidents."

"It is normal for a child to start wetting the bed again when hospitalized." Young children may exhibit regressive behaviors when they are under stress, such as occurs with hospitalization. Regressive behaviors can occur regardless of whether a child is fully toilet trained. Restricting fluids as the first step in a hospitalized child isn't appropriate; other causes of enuresis should be considered first. Telling the parents to not worry is not therapeutic.

A child, age 3, is admitted to the pediatric unit with dehydration after 2 days of nausea and vomiting. The parent tells the nurse that the child's illness "is all my fault." How should the nurse respond? "Do not worry. Your child will be fine." "Tell me more about why you think that." "When my child became dehydrated, I cried, too." "Do not be so hard on yourself."

"Tell me more about why you think that." Many parents feel responsible for their child's illness and may need instruction about the actual cause of the illness. Telling the parent, "Do not be so hard on yourself," "Do not worry," or "I cried, too" does not acknowledge or allow the parent to verbalize feelings. Acknowledge the parent's feelings without passing judgment and allow the parent to verbalize by stating, "Tell me more about why you think that."

The nurse is preparing a child, age 4, for cardiac catheterization. Which explanation of the procedure is most appropriate? "The test usually takes an hour." "You must sleep the whole time that the test is being done." "The special medicine will feel warm when it's put in the tubing." "Don't worry. It won't hurt."

"The special medicine will feel warm when it's put in the tubing." To prepare a 4-year-old child without increasing anxiety, the nurse should provide concrete information in small amounts about nonthreatening aspects of the procedure. Saying that it won't hurt may prevent the child from trusting the nurse in the future. Explaining the time needed for the procedure wouldn't provide sufficient information. Stating that the child will need to sleep could provoke anxiety; also, it's untrue.

A child who tests positive for the human immunodeficiency virus (HIV) is placed in foster care. The foster parents ask the nurse how to prevent HIV transmission to other family members. How should the nurse respond? "Wear gloves when you're likely to come into contact with the child's blood or body fluids." "Use isopropyl alcohol to clean surfaces contaminated with the child's blood or body fluids." "Don't let the child share toys with other children." "Make sure the child uses disposable plates and utensils."

"Wear gloves when you're likely to come into contact with the child's blood or body fluids." HIV is transmitted by blood and body fluids. Therefore, the nurse should respond by telling family members to wear gloves when anticipating contact with the child's blood or body fluids. Standard household methods for cleaning dishes and utensils are adequate, so the child needn't use disposable plates and utensils. To disinfect HIV-contaminated surfaces, the nurse should instruct the foster parents to use a solution of 1 part bleach to 10 parts water. The child may share toys; any toys that become soiled with the child's blood or body fluids should be disinfected with the bleach solution.

Which instruction should the nurse include in teaching about diet to parents of a preschool-age child who's prescribed corticosteroids? "Make sure your child follows a low-cholesterol diet." "Try to give your child bland foods." "Your child must remain on a low-fat diet." "You need to make sure your child consumes a low-sodium diet."

"You need to make sure your child consumes a low-sodium diet." Corticosteroids cause fluid retention; therefore, the parents should be instructed to make sure that their child follows a low-sodium diet. A bland, low-fat, or low-cholesterol diet aren't necessary with corticosteroid therapy. However, healthy lifestyle choices should be initiated at an early age.

A 5-year-old arrives in the clinic for a physical to enter school. Which potential child abuse findings should be brought to the health care provider's attention? Select all that apply. The child has abrasions on the knee. A patterned bruise is noted on the back. Parental description of accident does not match injury. The child clings to favorite blanket. Injuries in various stages of healing are documented.

A patterned bruise is noted on the back.; Parental description of accident does not match injury.; Injuries in various stages of healing are documented. The nurse is a mandated reporter when suspicious of child abuse. The health care provider would be notified if a patterned bruise, such as a buckle or brush, is noted. Also, if the description of how the child sustained the injury does not match with the injury, this is documented. If the child has multiple injuries in various stages of healing, further inquiry would be completed. Abrasions on the knee and having a favorite security object are common in this stage of development.

If a drug is available in suspension in a container, how should the nurse prepare the drug before administration? By diluting it with 5% dextrose solution By shaking or rolling the container so all drug particles are dispersed uniformly By filtering for undissolved particles and crushing them with a mortar and pestle By diluting it with normal saline solution

By shaking or rolling the container so all drug particles are dispersed uniformly Solid particles settle at the bottom of the container. Unless they are dispersed evenly through the solution, clients receiving doses from a mostly full container will get too little medication, and clients receiving doses from near the bottom of the container could get an overdose. The nurse should shake or in some cases (e.g., some insulins) gently roll a suspension before administration to disperse drug particles uniformly. Diluting the suspension and crushing particles aren't appropriate for this drug form.

The estranged parent of a preschool-age child comes to the hospital to visit the child. The child's medical record contains a restraining order that restricts the parent from visiting. When approached by the nurse, the parent becomes argumentative. What is the priority action by the nurse? Contact the local police. Contact the health care provider. Contact the security department. Contact the unit manager.

Contact the security department. The security department should be notified immediately about the visit of an argumentative parent of a child whose medical record contains a restraining order. Members of this department are specially trained to defuse such situations. If their efforts fail, they can immediately contact law enforcement officers, who can attempt to defuse the situation or remove the parent from the premises if necessary. The health care provider would not be able to help in this situation. The unit manager should be notified of the situation, but only after security has been contacted.

A preschool-age child has just been admitted to the pediatric unit with a diagnosis of bacterial meningitis. The nurse would include which recommendation in the nursing plan? Decrease environmental stimulation. Encourage the parents to hold the child. Monitor temperature every 4 hours. Take vital signs every 4 hours.

Decrease environmental stimulation. A child with the diagnosis of meningitis is much more comfortable with decreased environmental stimuli. Noise and bright lights stimulate the child and can be irritating, causing the child to cry, in turn increasing intracranial pressure. Vital signs would be taken initially every hour and temperature monitored every 2 hours. Children with bacterial meningitis are usually much more comfortable if allowed to lie flat because this position doesn't cause increased meningeal irritation.

The nurse is obtaining the history of a pediatric client, age 4. Which area usually takes longer to evaluate in a child than in an adult? Family health status Review of physiologic systems Past health status Developmental status

Developmental status Because children undergo rapid physiologic and psychological changes that affect growth and development, evaluating development usually takes longer in a child and involves more detail. Obtaining information about the child's achievement of specific developmental milestones is essential. Typically, the past health status, family health status, and review of physiologic systems take no longer to assess in a child than in an adult.

A child with a fractured left femur receives a cast. A short time later, the nurse notices that the toes on the child's left foot are edematous. Which nursing action would be most appropriate? Utilize a traction sling to raise the extremity. Contact the orthopedic surgeon. Elevate the foot of the bed. Apply ice to the toes and foot.

Elevate the foot of the bed. To relieve edema of the toes, the nurse should raise the affected extremity above the heart level such as by elevating the foot of the bed. Contacting the orthopedic surgeon is not necessary at this time. Applying ice may be effective but raising the extremity will be more effective. Using traction is not indicated.

A preschool-age child underwent a tonsillectomy 4 hours ago. Which data collection finding would make the nurse suspect postoperative hemorrhage? Refusal to drink clear fluids Vomiting of dark brown emesis Decreased heart rate Frequent swallowing

Frequent swallowing Frequent swallowing — an attempt to clear the throat of trickling blood — suggests postoperative hemorrhage. Emesis may be brown or blood-tinged after a tonsillectomy; only bright red emesis signals hemorrhage. The child may refuse fluids because of painful swallowing, not bleeding. Hemorrhage is associated with an increased, not decreased, heart rate.

A 4-year-old child has a tick embedded in the scalp. Which method should the nurse use to remove the tick? Burn the tick at the skin surface. Grasp the tick with tweezers and apply slow, outward pressure. Grasp the tick with tweezers and quickly pull the tick out. Surgically remove the tick.

Grasp the tick with tweezers and apply slow, outward pressure. Applying gentle outward pressure prevents injuring the skin and leaving parts of the tick in the skin. Surgical removal is indicated if portions of the tick remain in the skin. Burning the tick and quickly pulling the tick out may injure the skin and should be avoided.

When collecting data on a child with impetigo, the nurse expects which findings? Small, brown, benign lesions Honey-colored, crusted lesions Circular lesions that clear centrally Linear, threadlike burrows

Honey-colored, crusted lesions In impetigo, honey-colored, crusted lesions develop once the pustules rupture. Small, brown, benign lesions are common in children with warts. Linear, threadlike burrows are typical in a child with scabies. Circular lesions that clear centrally characterize tinea corporis.

The nurse is deciding whether to report a suspected case of child abuse. Which criterion is the most important for the nurse to consider? Inappropriate response of the child to the injury Inappropriate parental concern for the degree of injury Inability to question the parents about the injury because they aren't present Incompatibility between the history and the injury

Incompatibility between the history and the injury Incompatibility between the history and the injury is the most important criterion on which to base the decision to report suspected child abuse. The other criteria also may suggest child abuse but are less reliable indicators.

The nurse is evaluating a child with acute poststreptococcal glomerulonephritis (APSGN) for signs of improvement. Which finding typically is the earliest sign of improvement? Increased appetite Increased urine output Decreased diarrhea Increased energy level

Increased urine output Increased urine output, a sign of improving kidney function, typically is the first sign that a child with APSGN is improving. Increased appetite, an increased energy level, and decreased diarrhea aren't specific to APSGN.

A nurse is caring for a 4-year-old child with end-stage leukemia. The child's physician has ordered a lumbar puncture. His mother, who has legal custody, has refused to give consent for the child to undergo the procedure. However, the child's father is demanding that the procedure be performed. What should the nurse do first? Contact social services and the child's physician. Prepare the child for the lumbar puncture because the father wants the procedure to be performed. Inform the father that the procedure won't be performed because the mother didn't consent. Ask the child if he would like to have the procedure.

Inform the father that the procedure won't be performed because the mother didn't consent. The parent who has legal custody of a child has medical decision-making rights for that child. The other parent could contest the decision but would need to seek legal counsel. After informing the father that the procedure won't be performed at this time, the nurse should make the physician and social services aware of the situation in case additional problems arise.

The nurse is caring for a 5-year-old with several tiny blisters near the mouth, several of which are draining clear fluid and others which have a yellowish crust. Which teaching will the nurse provide to the client's parent? Wash the area with isopropyl alcohol to attempt to dry the drainage faster. Recognize that this is a normal finding that will run its course without intervention. Plan to administer antiviral therapy for at least seven days. Keep the child home from school until antibiotic therapy has been administered for 24 hours.

Keep the child home from school until antibiotic therapy has been administered for 24 hours. Impetigo contagiosa is the most common bacterial infection among young children. It rarely occurs in adults. Impetigo may follow another skin condition or infection. Generally, it begins in the superficial layers of the epidermis as a red inflamed vesicle on the face near the nose or mouth, or on the neck or hands. The vesicle breaks, leaking pus or fluid, which forms a honey-colored scab. The last stage is a red mark, which heals without leaving a scar. The sores may be itchy, but they are not painful. Impetigo can be caused by Staphylococcus aureus, Streptococcus pyogenes, and methicillin-resistant Staphylococcus aureus, all of which are highly contagious. The nurse will teach ways to minimize transmission, including the fact that the child should be kept home from school until they are no longer contagious, which is approximately 24 hours after starting antibiotic therapy. Isopropyl alcohol is contraindicated as this may be painful and can damage tissue integrity. This finding is not normal, and should not be permitted to continue as the infection will spread within the child, and then through transmission to others. Antiviral therapy does not address bacterial infections.

The mother of a preschooler recently diagnosed with type 1 diabetes mellitus makes an urgent call to the pediatrician's office. She says her child had an uncontrollable temper tantrum while playing and now is lethargic and hard to arouse. The nurse should instruct the mother to take which action first? Measure the child's blood glucose level. Force the child to drink orange juice. Call 911 because this is an emergency. Obtain a urine sample and measure the glucose level.

Measure the child's blood glucose level. In a child with type 1 diabetes mellitus, behavioral changes may signal either hypoglycemia or hyperglycemia; measuring the blood glucose level is the only way to determine which condition is present. Urine glucose measurement doesn't accurately reflect the current blood glucose level. Forcing a lethargic child to drink fluids could cause aspiration. After measuring the child's blood glucose level, the mother may need to take additional emergency measures such as administering insulin or a simple glucose source. If the child doesn't respond to these measures, the mother may need to call for emergency help.

A parent asks the nurse for advice on setting limits and disciplining a 4-year-old child. During the teaching session, which fact should the nurse emphasize? Children younger than age 5 rarely need to be punished. Parents should set firm, consistent limits. Parents should always use a "timeout" seat. Parents should enforce rules rigidly.

Parents should set firm, consistent limits. To deal with misbehavior most successfully, parents should set firm, consistent limits. Usually, parents should begin setting limits and implementing discipline around age 1, or when the child begins to crawl and explore the environment. Rigidly enforcing rules does not allow the development of autonomy and could lead to self-doubt. "Timeout" seats work well as a disciplinary measure but there may be times when it is not possible to utilize a "timeout" seat, for example, when shopping.

Encouraging children to engage in fantasy play and participate in their own care is a useful developmental approach for which pediatric age-group? Preschool age (3 to 5 years) Adolescence (10 to 19 years) Toddler (1 to 3 years) School age (5 to 10 years)

Preschool age (3 to 5 years) Children in the preschool age-group have a rich fantasy life. Combined with their strong concept of self, fantasy play and participation in care can minimize the trauma of being hospitalized. Adolescents should be allowed choices and control. School-age children are modest and need to have their privacy respected. Procedures should be explained to them. Toddlers should be examined in the presence of their parents because they fear separation.

A 4-year-old is hospitalized following alleged sexual abuse. The child is withdrawn and exhibits poor eye contact. Which nursing strategies encourage client communication? Select all that apply. Engage in play with toys and dolls. Provide paper and crayons and encourage coloring. Use touch by rubbing the shoulders or back. Read a book to establish a rapport. Provide a videotape on sexual abuse.

Provide paper and crayons and encourage coloring.; Engage in play with toys and dolls.; Read a book to establish a rapport. Children who are sexually abused exhibit signs of trauma and may withdraw. Nursing strategies to facilitate communication include developing a rapport with the child so he or she may feel more comfortable with communication. Providing age-appropriate play items to relieve stress and provide an outlet of emotions is helpful. Many times a preschooler will draw pictures to relate a message he or she finds difficult to describe. Acting out the actions with toys and dolls are also developmentally appropriate at this age. Touching may be uncomfortable for the child at this time due to the situation. A videotape is not appropriate at this age.

A preschool-age child refuses to take prescribed medication. Which nursing strategy would be most appropriate? Showing trust in the child's ability to cooperate even with an unpleasant procedure Making the child feel ashamed for not cooperating Explaining the medication's effects in detail to ensure cooperation Mixing the medication in milk so the child isn't aware that it's there

Showing trust in the child's ability to cooperate even with an unpleasant procedure To gain a preschooler's cooperation, the nurse should show trust and express faith in the child's ability to cooperate even with an unpleasant procedure. Hiding the medication in milk may foster mistrust. The nurse should provide simple, not detailed, explanations and should use terms the child can understand. Shaming the child is inappropriate and may lead to feelings of guilt.

The community health nurse is providing safety education to the caregivers of preschoolers. Which information does the nurse include? Select all that apply. Teach basic safety rules to the preschooler such as never crossing the street or playing with electrical outlets. Provide swimming lessons, but always maintain supervision around water even if the child knows how to swim. Enroll in cardiopulmonary resuscitation (CPR) and basic first aid courses. Allow preschoolers to be independent with handwashing and bathing, but ensure the water heater is set at 120°F (49°C) or below. Keep contact numbers for the local poison control center and an emetic such as syrup of ipecac readily available.​​​

Teach basic safety rules to the preschooler such as never crossing the street or playing with electrical outlets.; Provide swimming lessons, but always maintain supervision around water even if the child knows how to swim.; Enroll in cardiopulmonary resuscitation (CPR) and basic first aid courses. The nurse teaches the caregivers safety information that is appropriate for the preschooler's growth and development stage. Preschoolers can learn basic information related to safety, so the caregivers are encouraged to teach the child how to swim and to avoid hazards such as roadways and electrical outlets while recognizing supervision is still required. Although the water heater should be set at 120°F (49°C) or below, and children can wash their own hands, the nurse does not teach caregivers to allow the child to be independent with bathing; the preschooler should still be supervised when in the bathtub. Emergency preparedness such as taking CPR and first aid courses and having poison control center numbers available are encouraged, but the nurse does not encourage the caregivers to keep an emetic in the home, as induction of vomiting is not recommended in the event of poisoning.

For a child with tracheobronchitis, the nurse formulates a nursing diagnosis of Ineffective airway clearance related to thick secretions. After implementing interventions, the nurse expects which client outcome? The child exhibits an arterial oxygen saturation of 85%. The child exhibits clear breath sounds. The child exhibits a respiratory rate of 44 breaths/minute. The child exhibits increased anxiety.

The child exhibits clear breath sounds. Clear breath sounds indicate an improved respiratory status and airway clearance. A respiratory rate of 44 breaths/minute is high and indicates a respiratory problem. An arterial oxygen saturation of 85% is abnormally low. Decreased, not increased, anxiety would indicate effective airway clearance.

A 4-year-old child is diagnosed as having acute lymphocytic leukemia (ALL). The child's white blood cell (WBC) count and neutrophil count are both low. What teaching should the nurse reinforce with the parents? The child is at increased risk for bleeding. The child may experience shortness of breath. The child may experience fatigue. The child is at increased risk of infection.

The child is at increased risk of infection. One of the complications of both acute lymphocytic leukemia and its treatment is a decreased WBC count, specifically a decreased absolute neutrophil count. Because neutrophils are the body's first line of defense against infection, the child must be protected from infection. Bleeding is a risk factor if platelets or other coagulation factors are decreased. Decreased WBC and neutrophils do not lead to symptoms of fatigue and/or shortness of breath.

A 4-year-old child is seen in the pediatrician's office. The child is due for immunizations and the provider discusses with the caregiver the need for the immunizations. The nurse returns to the room to administer the immunizations and the caregiver refuses to sign the paperwork for the administration of the immunizations. What is the most appropriate action by the nurse? The nurse documents the interaction and escorts the caregiver and child out of the office. The nurse listens to the caregiver's concerns and discusses the risks of nonimmunization. The nurse states the child must have vaccinations for preschool and injects the child without permission. The nurse asks the provider to return to discuss the risks of nonimmunization.

The nurse listens to the caregiver's concerns and discusses the risks of nonimmunization. The nurse can document the interaction but does not need to escort the caregiver and child out of the office. The nurse should not state an opinion and inject the child without permission. The nurse is responsible for communication refusal, but asking the provider to return is not necessary as the caregiver has the right to refuse immunizations for the child.

The nurse is caring for a 5-year-old child with a femur fracture. The parent explains that the fracture occurred from a fall. The child's recollection of the event conflicts with the parent's explanation. What is the nurse's immediate responsibility? Call the police department to report abuse. Restrict parental visitation until abuse is ruled out. Keep the child safe, and assess for abuse. Question the parent about the discrepancy in stories.

The nurse listens to the caregiver's concerns and discusses the risks of nonimmunization. The nurse can document the interaction but does not need to escort the caregiver and child out of the office. The nurse should not state an opinion and inject the child without permission. The nurse is responsible for communication refusal, but asking the provider to return is not necessary as the caregiver has the right to refuse immunizations for the child.

The nurse is observing the parents of a 4-year-old child who has been admitted to the hospital. Which actions indicate that the parents understand how to best minimize anxiety during their child's hospitalization? Select all that apply. The parents bring the child's siblings for a brief visit. The parents bring the child's favorite toy to the hospital. The parents remain at the child's side during the hospitalization. The parents leave the room when the child undergoes a painful procedure. The parents explain all procedures to the child in great details. The parents punish the child if the child is not cooperative.

The parents bring the child's favorite toy to the hospital; The parents remain at the child's side during the hospitalization; The parents bring the child's siblings for a brief visit.

The parents of a preschool-age child ask the nurse about nutrition. Which statement about a preschooler's nutritional requirements is accurate? The quality of food that a preschooler consumes is more important than the quantity. Caloric requirements per kilogram of body weight increase slightly during the preschool-age period. Protein should account for 25% of a preschooler's total caloric intake. A preschooler's nutritional requirements differ greatly from those of a toddler.

The quality of food that a preschooler consumes is more important than the quantity. Food quality is more important than quantity; a high caloric intake may include many empty calories. A preschooler's caloric requirement is slightly lower than a toddler's. Overall, however, a preschooler's nutritional requirements are similar to a toddler's. A preschooler's nutritional requirements can be met by including two meat servings, three milk servings, four bread servings, and four fruit and vegetable servings.

A nurse is reinforce educating the parents of a 5-year-old child admitted to the pediatric unit with cystic fibrosis. Which statement concerning steatorrheic stools is most accurate? They're clay-colored. They're orange or green. They're frothy, foul-smelling, and fatty. They're black and tarry.

They're frothy, foul-smelling, and fatty. Children with cystic fibrosis have an abnormal electrolyte transport system in the cells that eventually blocks the pancreas, preventing the secretion of enzymes that digest certain foods such as protein and fats. This results in foul-smelling, fatty stool. Black, tarry stool is observed in clients who have upper GI bleeding, are on iron medications, or who consume diets high in red meat and dark-green vegetables. Clay-colored stool indicates possible bile obstruction. Orange or green stool may indicate intestinal infection.

A child, age 5, is brought to the pediatrician's office for a routine visit. When inspecting the child's mouth, the nurse expects to find how many teeth? Up to 15 Up to 32 Up to 10 Up to 20

Up to 20 A child may have up to 20 deciduous teeth by age 5. The first tooth usually erupts by age 6 months; the last, by age 30 months. Deciduous teeth usually are shed between ages 6 and 13.

A nurse is caring preoperatively for a preschooler scheduled for a ____________ removal. When explaining the location of the tumor to the parents, the following area of the urinary system impacted.

Wilms' Tumor

A nurse on the pediatric unit is caring for a group of preschool children. Which situation takes priority? a child with asthma who is wheezing with an oxygen saturation level of 96% a child admitted from the postanesthesia care unit who has a blood-saturated surgical dressing a child who develops a fever during a blood transfusion a physician waiting on the telephone to give the nurse a verbal order

a child who develops a fever during a blood transfusion A fever indicates an adverse reaction to the blood transfusion and requires immediate intervention. The post-surgical child is losing blood through the surgical incision, which also requires attention. However, managing the bleeding may take significant time. Between these two priorities, stopping the transfusion and beginning normal saline should be accomplished first and takes minimal time. Postponing stopping the blood to manage the bleeding from the post-op patient will cause potentially life threatening complications for the blood transfusion patient. The telephone call is important for medication changes and to prevent a delay in treatment. Airway management is also a high priority. At this point, the child is compensating with a reasonable oxygen saturation. In this scenario, the most critical situation is the blood transfusion reaction, which requires the quickest intervention to stop potential complications.

A nurse is working on the pediatric unit. Which assignment best demonstrates primary care nursing? caring for the same child from admission to discharge caring for different children each shift to gain nursing experience assuming the charge nurse role instead of participating in direct child care taking vital signs for every child hospitalized on the unit

caring for the same child from admission to discharge Primary care nursing requires that the primary nurse care for the same child (to whom the nurse is assigned) during a scheduled shift. The associate nurse is assigned to the child care assignment when the primary nurse has a day off or during the evening and night shifts. Caring for different children each shift doesn't promote continuity of care. Taking vital signs for every child on the floor is an example of team nursing, in which each member of the team is assigned one specific task for each child. The charge nurse may be directly involved in child care.

A nurse is finishing a shift on the pediatric unit. Because the shift is ending, which intervention takes priority? documenting the care provided during the shift completing input and output recording for the shift checking client pain levels for report to the next shift nurse checking to see that client orders have been transcribed

documenting the care provided during the shift Documentation should take top priority as this is the only way the nurse can legally claim that client interventions were performed. Checking client pain levels should be done throughout the shift and clients should be medicated so that they are not in need during busy change of shift times. Waiting until the end of the shift to review that client orders have been transcribed may lead to a delay in treatment and should be completed in a timely manner throughout the shift. Completing input and output recording can be assigned to a nurse assistant and should be delegated.

A nurse is collecting data on a 3-year-old who has ingested toilet bowl cleaner. What is the priority when gathering data from this child? obtaining the name of the product ingested from the parents observing skin integrity around the mouth evaluating the stool for blood evaluating the airway patency and respiratory status

evaluating the airway patency and respiratory status A child who has ingested a caustic poison, such as lye (found in toilet bowl cleaners), may develop edema, ulcers of the lips and mouth, pain in the mouth and throat, excessive salivation, dysphagia, and burns of the mouth, lips, esophagus, and stomach. Bleeding from burns in the GI tract can lead to pallor, hypotension, tachypnea, and tachycardia. All of the assessments would be made, but airway evaluation would take priority.

A preschool-age child scheduled for surgery in the morning is admitted to the facility for the first time. Which nursing action would ease the child's anxiety? explaining preoperative and postoperative procedures step by step explaining that the child will be "put to sleep" during the operation and will feel nothing having the child act out the surgical experience using dolls and medical equipment beginning preoperative teaching as soon as possible

having the child act out the surgical experience using dolls and medical equipment Having the child act out the surgical experience using dolls and medical equipment would ease anxiety and give the nurse an opportunity to clarify the child's misconceptions. Preschoolers have a limited concept of time, so the nurse should provide preoperative teaching just before surgery rather than starting it as soon as possible; also, a delay between teaching and surgery may heighten anxiety by giving the child a chance to worry or fantasize. The nurse should avoid using such phrases as "put to sleep" because these may have a dual or negative meaning to a young child. Long explanations are inappropriate for the preschooler's developmental level and may increase anxiety.

A parent tells the nurse that the parent's preschool-aged child with spina bifida sneezes and gets a rash when playing with brightly colored balloons, and that recently the child had an allergic reaction after eating kiwi fruit and bananas. Based on the parent's report, the nurse suspects that the child may have an allergy to kiwi fruit. latex. color dyes. bananas.

latex. If a child is sensitive to bananas, kiwi fruit, and chestnuts, she's likely to be allergic to latex. Children with spina bifida commonly develop an allergy to latex and shouldn't be exposed to it. Some children are allergic to dyes in foods and other products, but dyes aren't a factor in a latex allergy.

The nurse is teaching the mother of an ill child about childhood immunizations. The nurse should tell the mother that live virus vaccines shouldn't be administered to children with: cystic fibrosis. diabetes. asthma. leukemia.

leukemia. Leukemia causes immunosuppression, so inactivated — rather than live — viruses should be administered. Children with the other conditions listed can receive live virus vaccines because they aren't immunosuppressed.

A preschooler has vomiting, diarrhea, and a potassium level of 3.0 mEq/L. The physician prescribes an I.V. infusion of dextrose 5% in water and half-normal saline solution with 10 mEq of potassium chloride. The nurse knows that a child with vomiting and diarrhea needs fluids and potassium chloride to: avoid hyperglycemia. meet physiologic needs. promote normal stool elimination. eliminate the cause of diarrhea.

meet physiologic needs. A child with vomiting and diarrhea loses excessive fluids and electrolytes, which must be replaced. Fluid and electrolyte replacement can't eliminate the cause of diarrhea, which may result from various factors. Administration of I.V. fluids that contain glucose (such as dextrose 5% in water) may induce, not prevent, hyperglycemia. Fluid and electrolyte replacement has no effect on stool elimination.

A child, age 5, is to receive potassium added to the I.V. fluid. Before initiating this therapy, the nurse first should: evaluate respiratory rate and depth. check the child's apical pulse rate. monitor fluid intake and output. measure the blood pressure.

monitor fluid intake and output. Potassium shouldn't be added to the I.V. fluid until the child regains adequate kidney function, as indicated by balanced fluid intake and output and certain diagnostic test results. The other options aren't related to potassium administration.

A 4-year-old child is admitted to the burn unit with a circumferential burn to the left forearm. Which finding would alert the nurse to a potential complication that should be reported to the health care provider? +2 radial and ulnar pulses full range of motion and no pain numbness of fingers bilateral capillary refill less than 2 seconds

numbness of fingers Circumferential burns can compromise blood flow to an extremity, causing numbness. Capillary refill less than 2 seconds indicates a normal vascular blood flow. Absence of pain and full range of motion imply good tissue oxygenation from intact circulation. +2 pulses indicate normal circulation.

A child has arrived in the emergency department. The nurse documents the following findings in the chart understanding that they are consistent with which disease process? bronchiolitis asthma cystic fibrosis pneumonia

pneumonia The elevated fever, shallow respirations, decreased breath sounds, rales, harsh cough, and productive mucus are findings associated with pneumonia. Typically, there is no fever with asthma and cystic fibrosis, and bronchiolitis presents with a low-grade fever. Wheezing is associated with asthma and bronchiolitis; however, this was not found upon physical examination of this client. Bronchiolitis produces a dry cough, and pneumonia causes a productive, harsh cough. The client with cystic fibrosis typically presents with wheezing, rhonchi, and thick, tenacious mucus.

When assisting in developing a plan of care for a hospitalized child, the nurse knows that children in which age-group are most likely to view illness as a punishment for misdeeds? adolescence school age infancy preschool age

preschool age Preschool-age children are most likely to view illness as a punishment for misdeeds. Separation anxiety, although seen in all age group, is most common in older infants. Fear of death is typical of older school-age children and adolescents. Adolescents also fear mutilation.

The parents of a preschooler are refusing a blood transfusion to treat severe hypovolemia because they are Jehovah's Witnesses. The parents are aware of the potential consequences of refusing the treatment. The priority intervention for the nurse at this point is to: pursue obtaining orders for alternative treatments to a blood transfusion. notify the hospital ethics committee to overrule the parents decision. perform the blood transfusion as directed by the physician. contact social services and report the parents for abuse.

pursue obtaining orders for alternative treatments to a blood transfusion. Jehovah's Witnesses believe that a blood transfusion is the same as oral intake of blood, which they regard as a sin. The nurse caring for the child should not perform the transfusion, but should seek alternative therapies. Jehovah's Witnesses will accept fluid replacement, biomedical hemostats, and medications or surgical interventions to stop the bleeding causing the hypovolemia. It is not appropriate for the nurse to call social services or the ethics committee, because the parents are acting in what they consider to be their child's best interest, and their religious decisions are supported by law.

The nurse is preparing to insert an intravenous cannula on a preschooler. In which position should the nurse place the child to best reduce the risk of injury during the procedure? sitting on a caregiver's lap and secured in a comfortable position seated in a chair facing away from the nurse with the arm supported in the position the preschooler chooses as most comfortable in the supine position with a second person securing the child's arm

sitting on a caregiver's lap and secured in a comfortable position Ideally, the preschooler's caregiver should be taught how to use a "comfort holding technique" for the insertion of the intravenous cannula. By increasing the child's sense of security there is less likelihood of the child reacting in a way that could result in injury. The comfort holding positions are specific to the child's age and the procedure being performed, but all involve being seated on the caregiver's lap and being secured in a comfortable position while allowing access to the body part needed for the procedure (in this case, an arm). For intravenous insertion, the child is often facing the parent or caregiver, but this can be modified based on preference. Being placed in the supine position can make the preschooler feel more vulnerable and increase fear. The preschooler could be given an option to face toward the caregiver or the nurse but cannot be offered to freely choose any position at this age. The child should be secured by a caregiver and not seated alone on a chair.