PEDI HESI
The nurse plans to administer 10 mcg/kg of digoxin elixir as a loading dose to a child who weighs 55 pounds. Digoxin is available as elixir of 50 mcg/ml. How many ml of the digoxin elixir should the nurse administer to this child?
5 ml
The nurse is caring for a female client with scoliosis who had a posterior spinal fusion and is in a body jacket cast. Which findings indicates cast syndrome? A. Abdominal distention B. Diminished pulses in the foot C. Hot spot felt on the cast D. Musty, unpleasant odor to cast
A. Abdominal distention
The parents of a 14-year-old girl tell the nurse that their daughter dresses as a tomboy and plays baseball one day and the next day dresses in feminine clothing and is a teenage drama queen. What information should the nurse use to respond to the parents? A. Adolescents try on different roles while seeking their identity B. Teenagers need a strong role model to emulate. C. Such erratic behavior needs further investigation D. 14 year olds often try to please parents with role choices
A. Adolescents try on different roles while seeking their identity
A 6 y/o child is admitted in the ED with a SBP of 58 mmHg. What action should the nurse take first? A. Alert the healthcare provider B. Initiate IV fluid replacement C. Comfort the child D. Assess responsiveness
A. Alert the healthcare provider
A 14 y/o returns to the unit after corrective surgery for scoliosis. In the immediate post-operative period, the nurse should include which actions (select all that apply) A. Assess bowel sounds ever 4 hours B. Elevate the head of the bed 30 degrees C. Ambulate for 5 minutes 12 hours post-operative D. Record intake and output every 8 hours E. Give morphine sulfate 2 mg IV every 4 hours PRN F. Initiate a logrolling schedule every 2 hours
A. Assess bowel sounds ever 4 hours D. Record intake and output every 8 hours E. Give morphine sulfate 2 mg IV every 4 hours PRN F. Initiate a logrolling schedule every 2 hours
A nurse reviews the methods for preventing recurring UTIs. Which response indicates a need for further teaching: A. Bathes the child nightly with liquid bubbles added B. Increases oral fluids and encourages the child to void frequently C. Provides the child with cotton underwear for daily use D. Teaches the child to cleanse perineal area from front to back
A. Bathes the child nightly with liquid bubbles added
An adolescent female's susceptibility to vulvitis is most likely related to which causative factor? A. Contact with fabric dyes B. Menarche C. Frequent sexual activity D. Urinary incontinence
A. Contact with fabric dyes
A 7 m/o infant is admitted with nonorganic failure to thrive. To aid the child's growth and development, which intervention is most important for the nurse to implement. A. Demonstrate feeding strategies and infant cues that indicate hunger and satiation B. Encourage the parents to participate in a planned program of play with the infant. C. Refer the parents for psychological counseling to identify parental detachment D. Provide instructions about formula preparation and feeding schedules
A. Demonstrate feeding strategies and infant cues that indicate hunger and satiation
A mother brings her 6 m/o infant to the clinic for a well baby routine exam. Which vaccine(s) should the nurse verify the infant has received. Select all that apply. A. Hib B. DTaP C. MPSV4 D. MMR E. HEPb F. IPV
A. Hib B. DTaP E. HEPb F. IPV
What is a priority nursing diagnosis for a child in the subacute stage of Kawasaki disease? A. High risk for altered tissue perfusion, cardiopulmonary B. High risk for fluid volume deficit C. Alterations in skin integrity D. Risk for imbalanced body temperature, hyperthermia
A. High risk for altered tissue perfusion, cardiopulmonary
What snack is best to provide a 6-year-old child on prescribed bedrest while receiving treatment for osteomyelitis? A. Milkshake B. Soup broth C. Applesauce D. Popsicle
A. Milkshake
Muscular dystrophy is characterized by which condition: A. Skeletal muscle degeneration B. Cardiac damage C. Stressed induced tremor and trembling D. Seizure activity
A. Skeletal muscle degeneration
The nurses calculates a 4 mL dose of Digoxin to a 8 m/o. What should the nurse do? A. Suspect dosage error and do not give the dose B. Check HR and administer dose by letting the infant suck it through a nipple C. Check HR and administer by placing it to the back and side of the mouth D. Mix dose with juice to disguise its taste
A. Suspect dosage error and do not give the dose
A man who was recently diagnosed with Huntington's disease asks the nurse if his adolescent son should be tested for the disease. What is the best response? A. Testing is needed because there is a 50% risk of passing the gene to each offspring B. Autosomal dominant disorders, such as Huntington's, cannot be inherited from the parent C. Genetic counseling should be provided to ensure an informed decision by the family D. Positive genetic testing may contribute to insurance discrimination that denies coverage
A. Testing is needed because there is a 50% risk of passing the gene to each offspring
Which clinical finding should the nurse expect a child with nephrosis to exhibit? A. Urine protein 3+ to 4+ B. Elevated blood pressure C. Blood-tinged urine D. Elevated temperature
A. Urine protein 3+ to 4+
The nurse is instructing an adolescent with bulimia and a low potassium level about the risk of complications. Which medical problem should the nurse focus on A. cardiac arrhythmias B. gastrointestinal reflux C. anemia D. heightened neurologic reflexes
A. cardiac arrhythmias
While assessing the apical pulse of a 13 y/o, the nurse determines that the rate is 88 bpm and the rhythm is irregular. The heart rate is phasic with respirations increasing during inspiration and decreasing with expiration. What action should the nurse take? A. continue the cardiac examination B. Re-assess the apical pulse in 15 minutes C. Inquire about daily caffeine intake D. Schedule a consultation with a cardiologist
A. continue the cardiac examination
While assessing an 18 m/o the nurse notes that the toddler has a rounded pot-belly abdomen, marked lordosis and swayback, short slightly bowed legs, and a large head. What action should the nurse take A. document general physical appearance of a normally developed toddler B. refer the findings to the healthcare provider for diagnostic studies for hydrocephalus C. plot the findings on the growth chart within the parameters of delayed physical maturation D. review the dietary intake for indications of a vitamin deficiency or malnutrition
A. document general physical appearance of a normally developed toddler
The nurse is assessing the coping behaviors of the parents whose child has been recently diagnosed with a chronic illness. What reaction by the parents is considered positive A. endowing the illness with meaning B. entertaining an unrealistic future plan for the child C. refusing to believe the child is ill D. placing complete faith in religion to the point of relinquishing own responsibility
A. endowing the illness with meaning
A spanish speaking 5 y/o starts kindergarten in an english speaking school. The child cries. How should the nurse document this: A. experiencing culture shock B. refuses to participate in school activities C. going through minority group discrimination D. lacks the maturity needed in school
A. experiencing culture shock
Which neurological test should the nurse implement to assess cerebellar function in a 5 year old with symptoms of hyperactivity? A. finger to nose B. quadriceps reflex C. two point discrimination D. ability to follow directions
A. finger to nose
An 8 y/o boy recently diagnosed with diabetes mellitus is admitted to the ICU with DKA. What is the highest priority: A. initiate an IV infusion B. Place on cardiac monitor C. Collect specimens for serum electrolytes D. Obtain fingerstick glucose
A. initiate an IV infusion
The nurse is caring for an irritable, lethargic 18 m/o child who swallowed several OTC antihistamines and hour ago. What should the nurse do A. initiate gastric lavage B. encourage oral intake of water or milk C. give a dose of ipecac syrup D. administer naloxone
A. initiate gastric lavage
A mother brings her 6 m/o to the clinic. She comments I want to go back to work but I don't want my baby to suffer. How should the nurse respond A. let us talk about the child care options that are best for the child B. go back to work now so the infant will get used to being with others C. find a good babysitter close to the house D. stay home until the child starts school
A. let us talk about the child care options that are best for the child
During a well visit, the nurse hides a block under the baby's blanket, and the baby looks for the block. Which normal milestone does this indicate A. object permanence B. separation anxiety C. object prehension D. associative play
A. object permanence
A 6 y/o squirms and giggles when the nurse begins to palpate the abdomen. What should the nurse do A. place the child's hand under the examiner's hand while palpating B. press the abdomen with the child bearing down and holding breath C. postpone the abdominal palpation until the next examination D. touch the abdomen firmly as the child takes short, quick breaths
A. place the child's hand under the examiner's hand while palpating
The nurse is assessing a child for neurological soft signs. What finding is most significant A. poor coordination and sense of position B. inability to move tongue in all directions C. presence of vertigo D. loss of visual acuity
A. poor coordination and sense of position
The nurse is assessing an infant with diarrhea and lethargy. Which finding indicates early dehydration: A. tachycardia B. bradycardia C. increased skin turgor D. dry mucus membranes
A. tachycardia
The nurse should instruct the parents of an 8-year-old child who has sickle cell anemia to be alert for which complaint from the child: A. "I am shorter than everyone else" B. "I am really hot and thirsty." C. "I don't want to eat any vegetables." D. "I have to urinate every few hours."
B. "I am really hot and thirsty."
An infant weight 7 lb at birth. How much should the nurse expect the infant to weigh at 6 months. A. 12 lb B. 14 lb C. 17 lb D. 21 lb
B. 14 lb
A mother tells the nurse that her children are asking questions about divorce but one male child says he is sorry that he caused the divorce. What age is most likely to feel this way A. 8 years B. 4 years C. 13 years D. 1 year
B. 4 years
What is the priority nursing intervention for a 12 y/o newly diagnosed with bacterial meningitis: A. Monitor for increased ICP and do frequent neurons vital sign checks B. Administer broad spectrum antibiotics before results of culture and sensitivity tests are returned C. Maintain seizure precautions to protect the client from injury D. Continue with pain management and provide comfort measures
B. Administer broad spectrum antibiotics before results of culture and sensitivity tests are returned
The nurse notices that the hem of a skirt on a pre-adolescent girl is uneven when she comes to the clinic. What procedure should the nurse follow to examine the girl for scoliosis? Arrange the examination process from first on top to last on the bottom. A. Examine for scapular prominence B. Ask the girl to remove her shirt but leave on her bra or swimsuit top C. Instruct the girl to bend at the waist so back is parallel to the floor D. Look for asymmetry in the hip area
B. Ask the girl to remove her shirt but leave on her bra or swimsuit top D. Look for asymmetry in the hip area C. Instruct the girl to bend at the waist so back is parallel to the floor A. Examine for scapular prominence
A 4 y/o is brought to the ED for a laceration on the right foot. What action should the nurse implement to help the child in coping with the emergent experience? A. Give the child some time after explaining procedures B. Avoid using jargon such as shot when giving care C. Remind the preschooler how big children should act D. Avoid the use of bandages to keep wounds open to air
B. Avoid using jargon such as shot when giving care
A 12 y/o male client tells the nurse that he is happy to be taking growth hormones because now he can expect to grow and be just as tall as his friends. How should the nurse respond. A. You will grow with this medicine and are likely to be taller than anyone in your family. B. Being taller is important to you and taking your injections will help achieve that goal C. Although being tall is important to you, remember there are far more important characteristics than height D. You must remember that this treatment regimen is not always effective
B. Being taller is important to you and taking your injections will help achieve that goal
When plotting a 20 w/o infant's weight on a standardized growth chart, the nurse determines that the child's weight is between the 2nd and 3rd percentile. What action should the nurse take? A. Obtain a 24 hour nutritional history before making any conclusions B. Compare this weight with previous weights recorded in the child's record C. Teach the parents about interventions for failure to thrive syndrome D. Evaluate the parent's body build in relation the infant's weight
B. Compare this weight with previous weights recorded in the child's record
The community health nurse teaches the parents of school-aged children about the need for fluoride as part of a dental health program. Which statement by the parents indicates understanding? A. Having our children brush with fluoride toothpaste is not effective B. Dental caries can be prevented through fluoridation of public water C. Use of fluoride in water is mostly effective during initial tooth formation D. Excessive amounts of fluoride will make teeth turn brittle and yellow
B. Dental caries can be prevented through fluoridation of public water
When screening a 5 year old for strabismus, what action should the nurse take A. Have the child identify colored patterns on polychromatic cards B. Direct the child through the six cardinal position of glaze C. Inspect the child for the setting sun sign D. Observe the child for blank, sunken eyes
B. Direct the child through the six cardinal position of glaze
The nurse is preparing to catheterize an 8 year old child. Before starting the procedure, which action should the nurse take first. A. Obtain the parent's cooperation before initiating the procedure B. Explain to the child and the parents that the procedure needs to be done C. After talking with the parents about the procedure, ask them to leave the room D. Provide the child with privacy by conducting the procedure in the treatment room
B. Explain to the child and the parents that the procedure needs to be done
When assessing a preschooler, which finding warrants further assessment by the nurse? A. Talks about an imaginary friend B. Gains 2 pounds in 12 months C. Able to ride a tricycle D. Dresses independely
B. Gains 2 pounds in 12 months
A child who has been vomiting for 3 days is admitted for correction of fluid and electrolyte imbalances. What acid base imbalance is the child likely to exhibit? A. Respiratory Acidosis B. Metabolic Alkalosis C. Respiratory Alkalosis D. Metabolic Acidosis
B. Metabolic Alkalosis
A hospitalized child stiffens and starts to seize as the nurse enters the room. What actions should the nurse take? Select all that apply. A. Instruct the parents to leave the room. B. Pad side rails with available pillows and blankets. C. Notify the emergency response team. D. Monitor duration and progress of the seizure. E. Turn client to the side if possible
B. Pad side rails with available pillows and blankets. D. Monitor duration and progress of the seizure. E. Turn client to the side if possible
A crying toddler has a BP measurement of 120/70 mmHg. What action should the nurse implement? A. ask the parent if the child has a history of hypertension B. Quiet the child and retake the BP C. Document the finding and recheck in 4 hours D. Notify the healthcare provider of the measurement
B. Quiet the child and retake the BP
A child with nephrotic syndrome is receiving prednisone. Which priority nursing diagnosis should the nurse include in the plan of care? A. Disturbed body image B. Risk for infection C. Risk for bleeding D. Nausea
B. Risk for infection
A child is brought to the ED with sweating, chills, and snake fang-like puncture marks on the calf. What action should the nurse implement after the snake is identified? A. Reassure the child and parent B. Secure the antivenin C. Apply a tourniquet to the leg D. Ambulate the child
B. Secure the antivenin
What should the nurse asses last when examining a 5 y/o A. Abdomen B. Throat C. Heart D. Lungs
B. Throat
A nurse who is working in the poison control center receive a call from a parent of a 16 m/o child who drank 2 ounces of Tylenol. What should the parents do: A. Give the child a glass of whole milk B. Transport to ED for gastric decontamination C. Administer oral syrup of ipecac D. Obtain oral activated charcoal tablets from the pharmacy
B. Transport to ED for gastric decontamination
A child with a penetrating eye injury comes to the school clinic. What action should the nurse implement A. irrigate the affected eye copiously with a cool sterile saline solution B. apply a fox shield to the affected eye and any type of patch to the other eye C. remove the object impaired int he eye and then apply a regular eye patch D. place an ice bag over the eye until the healthcare provider is seen
B. apply a fox shield to the affected eye and any type of patch to the other eye
The parents of a toddler brought to the clinic tell the nurse that their child becomes upset even with the smallest changes in the environment. How should the nurse respond A. a toddler should be exposed to different routines to promote adapting to new experiences B. children of this age are comfortable with ritualism and display global thinking C. objects should be frequently moved in the environment to teach the child to acclimate to change D. a child is insecure b/c trust is not fostered and developed during infancy
B. children of this age are comfortable with ritualism and display global thinking
The nurse is examining a neonate at age 10 minutes. Which site should the nurse expect to see nonpathologic cyanosis A. bridge of nose B. feet and hands C. circumoral area D. mucus membranes
B. feet and hands
Which research finding provides evidence based practice for an infants risk for SIDS A. breastfeeding reduces the risk for and the incidence of SIDS B. infants should be positioned supine or supported laterally to sleep C. the prone position should ben used when an infant sleeps after feeding D. the peak incidence occurs between the ages of 1 and 2 months
B. infants should be positioned supine or supported laterally to sleep
The nurse at a clinic is advising the parents of an 8 y/o about health and safety. What information is important A. give syrup of ipecac in case of accidental ingestion or poisoning B. install stair guards or gates in the home C. use of a car seat is optional if a lap/shoulder belt is in place D. start toilet training with a child-sized potty
B. install stair guards or gates in the home
The low birth weight infant requires a neutral environment. What action should the nurse implement A. avoid using disposable diapers B. maintain a high humidity atmosphere C. continue cool oxygenation via a hood D. use wool blankets for covers
B. maintain a high humidity atmosphere
A 4 m/o breastfeeding infant is at the 10th percentile for weight and the 75th percentile for height. How should the nurse interpret the findings A. failure to thrive B. normal growth curve of a breast-fed infant C. milk allergy D. inadequate milk supply in the mother
B. normal growth curve of a breast-fed infant
A 5 y/o child is one day postoperative and has bilateral eye patches and should be out of bed. What is the priority intervention should the nurse implement before leaving the bedside A. allow the child to assist in feeding himself B. orient the child to the immediate surroundings C. allow the parents to stay in the room with the child D. speak to the child when entering the room
B. orient the child to the immediate surroundings
The nurse is triaging a child with a fever who is brought to the ED. Which finding requires immediate attention: A. thick yellow rhinorrhea B. prolonged exhalations C. oxygen saturation is 95% D. frequent nonproductive cough
B. prolonged exhalations
After discussion the introduction of solid foods of a 6 m/o infant. What should be the first food to give A. yellow vegetables B. rice cereal C. egg yolks D. fruits
B. rice cereal
The nurse observes the interactions of a 2 y/o who says no even when yes is what the child wants to say. The parent wants to know why the child is so negative. How should the nurse respond A. the toddler is exhibiting an example of ritualistic behavior B. the child is trying to assert autonomy through negativism C. a 2 y/o often acts in the opposite way to get attention D. this age child is testing the limits of the parent's patience
B. the child is trying to assert autonomy through negativism
a 4 y/o child who is ventilator dependent is receiving tube feedings. List in order which actions the nurse should implement. A. Refuse to feed the child orally, because the risk is too high B. Ask the parents to negotiate a change in feeding methods with the healthcare provider C. Acknowledge the request and then explore with the family the available options for care D. Set additional goals for feeding the child with the parents
C. Acknowledge the request and then explore with the family the available options for care D. Set additional goals for feeding the child with the parents A. Refuse to feed the child orally, because the risk is too high B. Ask the parents to negotiate a change in feeding methods with the healthcare provider
A 3-month-old with myelomeningocele and atonic bladder is catheterized every 4 hours to prevent urinary retention. The home health nurse notes that the child has developed episodes of sneezing, urticaria, watery eyes, and a rash in the diaper area. What action is most important for the nurse to take? A. Auscultate the lungs for respiratory pneumonia. B. Draw blood to analyze for streptococcal infection C. Change to latex-free gloves when handling infant D. Apply zinc oxide to perineum with each diaper change
C. Change to latex-free gloves when handling infant
The parents of an adolescent male with Ewing Sarcoma ask the nurse what is the most significant factor contributing to their sons prognosis: A. Age of onset B. Gender of child C. Degree of metastasis D. Appearance on X-Ray
C. Degree of metastasis
The nurse is assessing an 8-month-old who has a cough, axillary temperature of 100°F, and rhinorrhea. What information is most important for the nurse to obtain from this child's mother? A. Living conditions B. Labor and delivery history of the infant. C. Immunization status of the infant D. Alcohol and drug intake of the mother
C. Immunization status of the infant
The nurse is developing the plan of care for a school-aged boy with a chronic disability. The child frequently cries about being different from his siblings and wants others to do things for him that he is capable of doing for himself. To assist the family in coping with this child's chronic illness, which intervention is most important? A. Suggest that all the children are included in family decision making. B. Evaluate the proper use of equipment that is provided to improve the child's lifestyle. C. Recommend the use of consistent discipline and reward for acceptable behavior D. Encourage the parents to role model ways to act when one is disappointed
C. Recommend the use of consistent discipline and reward for acceptable behavior
The nurse is collecting a blood sample from a newborn for a screen of phenylketonuria. When should the nurse obtain the blood sample A. 14 days after birth B. at birth from cord blood C. after ingestion of a source of protein D. before oral feedings are initiated
C. after ingestion of a source of protein
An infant with developmental dysplasia of the hip is placed in a Pavlik harness. What instructions should the nurse include in a teaching plan for the parents? A. apply lotion or powder to minimize skin irritation B. put clothing over harness for maximum effectiveness C. check for red areas under the straps 3 times a day D. use a thin absorbent disposable diaper over the harness
C. check for red areas under the straps 3 times a day
When administering a lavage feeding to a school age child which action should the nurse implement A. administer feedings over 5 to 10 minutes B. check the placement of the tube by inserting 20 ml of sterile water C. position the child on the right side after administering the feeding D. lubricate the tip of the feeding tube with petroleum jelly to facilitate passage
C. position the child on the right side after administering the feeding
A 14 y/o is brought the ED after a biking accident. How should the nurse interact with the kid. A. have the parents remain with the adolescent at all times. B. furnish rewards for cooperation during procedures C. provide clear explanations while encouraging questions D. limit the number of choices to be made by the adolescent
C. provide clear explanations while encouraging questions
What sign of malignant hyperthermia should the nurse assess for during the preoperative period in a child receiving general anesthesia A. apnea B. decreased blood pressure C. tachypnea D. bradycardia
C. tachypnea
The father of an 8 y/o wants his child to succeed in soccer. The child wants to play chess and feels like a failure in soccer. How should the nurse respond A. the child has an introverted personality and should be encouraged to play isolated games B. the father should encourage the son to participate in team sports instead of less physical activities C. the child should be given opportunities to achieve a sense of competency in an area he chooses D. the father should decrease his expectations to give the son a chance to succeed.
C. the child should be given opportunities to achieve a sense of competency in an area he chooses
A 15 y/o girl tells the school nurse that she wants to have a baby. How should the nurse respond? A. "Have you talked with your parents about this?" B. "Will you be able to support the baby?" C. "Do you have plans to continue school?" D. "Can you tell me how your life will be if you have an infant?"
D. "Can you tell me how your life will be if you have an infant?"
A 2-year-old is receiving care in the ED for a deep laceration on the head. What action should the nurse implement to facilitate the child's cooperation? A. Let the child decide whether to sit up or lie down for procedures. B. Direct the parents to remain outside the treatment room C. Keep the child physically restrained during nursing care. D. Allow the child to hold a favorite toy or blanket
D. Allow the child to hold a favorite toy or blanket
Which site should the nurse assess to obtain the pulse rate for a 1 y/o A. Femoral B. Carotid C. Radial D. Apical
D. Apical
A child with hemophilia arrives at the clinic with a swollen knee after falling off a bicycle. What action should the nurse implement first? A. Initiate an IV site and begin infusing normal saline. B. Type and cross for possible transfusion. C. Monitor the child's vital signs frequently D. Apply ice pack and compression dressing to knee
D. Apply ice pack and compression dressing to knee
The nurse is caring for a 9 y/o male child who frequently speaks about sex and uses correct sexual vocabulary. What action should the nurse implement with this child? A. Ask the child whether he was sexually abused. B. Involve the child in teaching sex information to peers. C. Inquire where the child got this important information D. Ascertain what the child understands about sex
D. Ascertain what the child understands about sex
A 10-year-old girl is diagnosed with inflammatory bowel disease (IBD). Her mother is concerned that she will experience developmental delays as the result of this disorder. How should the nurse response? A. She will only experience developmental delays if weight loss cannot be controlled. B. Scheduling a private tutor can help to prevent developmental delays C. She is at a high risk for a number of different problems, including developmental delays. D. Growth failure is a concern, but developmental delays are not likely to occur
D. Growth failure is a concern, but developmental delays are not likely to occur
A child with possible Duchenne muscular dystrophy undergoes an electromyelogram. Following the procedure, the child's parents tell the nurse that the child is complaining of sore muscles. How should the nurse respond? A. Explain that muscle aches and pain are commonly experienced by children with this form of muscular dystrophy. B. Advise the parents that children with chronic diseases may seek attention by reporting pain or other unpleasant symptoms. C. Encourage the parents to monitor the child's body temperature for the next 24 hours and report a rise above 101°F. D. Offer reassurance that muscle soreness following this procedure is temporary and does not indicate a problem
D. Offer reassurance that muscle soreness following this procedure is temporary and does not indicate a problem
The nurse is developing a plan of care for a newborn with a colostomy due to anal agenesis, and the infant has had 3 loose stools since surgery yesterday. Which nursing diagnosis is the highest priority A. Anxiety of parents related to newborn's condition B. Alteration in bowel elimination C. Pain related to postoperative condition. D. Potential for fluid volume deficit
D. Potential for fluid volume deficit
A 3 y/o boy is brought to the ED because of a possible diazepam (Valium) overdose. He is lethargic and confused, and his vital signs are: pulse rate 100 bpm, RR 20 bpm, and BP 70/30. What is the highest priority? A. Insert a foley catheter to monitor renal functioning B. Insert an orogastric tube for gastric lavage C. Draw blood for stat chemistries and blood gases. D. Prepare a set-up for an endotracheal intubation
D. Prepare a set-up for an endotracheal intubation
When caring for a child who has pertussis that is in the paroxysmal stage, what is the most important intervention A. Maintain a liquid diet B. Increase protein intake C. Offer the child a regular diet D. Provide small frequent meals
D. Provide small frequent meals
A child with acute laryngotracheobronchitis (croup) received epinephrine 2 hours ago in the emergency room, and is now being prepared for discharge to the home. The nurse should instruct the parents to take which action if the child's uncontrolled coughing reoccurs. A. Call for emergency transportation to the hospital. B. Increase the fluid intake to liquefy the secretions. C. Administer a dose of the prescribed cough medicine. D. Sit with the child in the bathroom with hot steam
D. Sit with the child in the bathroom with hot steam
When conducting a hygiene class for adolescent girls. It is important for the nurse to include which instruction about preventing toxic shock syndrome: A. Wear cotton underwear B. Use super absorbant tampons C. Douche every month following menstruation D. Wash your hands before inserting a tampon
D. Wash your hands before inserting a tampon
The mother of a 2 m/o reports that she often lets the baby cry in the middle of night instead of going to it. What should the nurse say A. picking up the infant in the middle of the night fosters dependency on the mother B. an infant is learning to manipulate others when the infant is picked up unnecessarily C. a 2 m/o who does not sleep through the night should be evaluated further D. a sense of trust is developed in an infant when others respond to the infants cry
D. a sense of trust is developed in an infant when others respond to the infants cry
When assessing the breath sounds of an 18 m/o who is crying. What should the nurse do A. ask the parent to quiet the child so breath sounds can be auscultated B. document that the assessment is not available because the child is crying C. auscultate and document breath sounds, noting that the child was crying at the time D. allow the child to initially play with the stethoscope, and distract during auscultation
D. allow the child to initially play with the stethoscope, and distract during auscultation
The nurse plans to mix a medication with food to make it more palatable for a child. Which food should be administered A. formula or milk B. syrup C. orange juice D. applesauce
D. applesauce
What intervention should the nurse implement to help keep a 6 m/o infant calm during an assessment A. give the infant a soft cuddly toy to hold B. remove the pacifier from the infants mouth C. distract the infant with noise or bright lights D. encourage the parent to hold the infant
D. encourage the parent to hold the infant
What is the best action for the nurse to take when initiating contact with a toddler for the first time A. ask the toddler to point to where it hurts B. tell the child your name and that you are the nurse C. call the child by name while picking up the toddler D. kneel in front of the toddler and speak softly to the child
D. kneel in front of the toddler and speak softly to the child
The mother of a 2 y/o who just received the first DTap asks the nurse what symptoms to expect. How will the nurse respond: A. seizures are common and require anticonvulsant medication B. most children do not experience any reaction C. the most common reaction is a whole body rash that develops into itchy vesicles D. mild reactions are common and most frequently include low grade fever
D. mild reactions are common and most frequently include low grade fever
The nurse is assessing a clients skin turgor and grasps the skin on the abdomen between the thumb and index finger, pulls it taut, and quickly releases it. It remains suspended and tented for a few seconds and then slowly falls back. How should the nurse document this A. adequate hydration B. assessment inconclusive C. normal skin elasticity D. poor skin turgor
D. poor skin turgor
During the well assessment the parents of a 4 y/o express concern that their child chatters while playing alone. What should the nurse say: A. concern for psychological development is warranted so further testing is required B. the child is attempting to formulate a secondary language C. this is an attempt by the child to form an imaginary social base D. private speech is normal at this age and serves as a problem solving tool
D. private speech is normal at this age and serves as a problem solving tool
The nurse is caring for a premature infant who needs na IV access restarted. What action should the nurse take when using adhesive tape A. employ solvents to remove adhesives instead of pulling on skin B. avoid using tape and adhesives until skin is more mature C. use scissors carefully to remove tape instead of pulling tape off D. remove adhesives with water, mineral oil, or petrolatum
D. remove adhesives with water, mineral oil, or petrolatum
A newborn who is breastfeeding is diagnosed with galactosemia. What action should the nurse implement? A. give galactokinase with breast milk B. add amino acid to breast milk C. substitute a lactose containing formula D. stop the infant breastfeeding
D. stop the infant breastfeeding
How should the nurse measure the length of a 14 m/o child A. prone recumbent B. side lying C. standing height D. supine recumbent position
D. supine recumbent position
A mother expresses concern to the nurse about the behavior of her 15 y/o who is frequently finding fault and criticizing her. A. the family value system may need to be changed to meet the teen's changing needs B. parents should relinquish their relationship with their teen to the teen's peers. C. conflicts int the parent-teen relationship are to be expected during adolescence D. teens create psychological distance from parents in order to separate from them
D. teens create psychological distance from parents in order to separate from them
Which finding should the nurse in the ED identify as an indicator that a 3 y/o has been mistreated? A. the toddler does not remember how the injury occurred. B. the parents are extremely calm in the emergency room C. the child was doing something unsafe when the injury occurred. D. the injury sustained is highly unusual for a 3 y/o child
D. the injury sustained is highly unusual for a 3 y/o child
During a well baby visit the parents explain that a soft bulge appears in the groin of their 4 month old son when he cries or strain stooling. The infant is schedule for surgical repair of the inguinal; hernia in two weeks. The parent should be instructed to take which measure if the hernia becomes incarcerated prior to the surgery? a. Use rectal thermometer for straining on stool b. Gently manipulate the hernia for reduction c. Offer oral electrolyte fluids for comfort d. Give acetaminophen or aspirin for crying
b. Gently manipulate the hernia for reduction
A 16 year old male client who has been treated in the past for a seizure disorder is admitted to the hospital. Immediately after admission he begins to have a grand mal seizure. Which action should the nurse take? a. Obtain assistance in holding him to prevent injury b. Observe him carefully c. Call a CODE d. Place a padded tongue blade between the teeth
b. Observe him carefully
Which nursing intervention is most important to include in the plan of care for a child with acute glomerulonephritis A. encourage fluid intake b. promote complete bed rest c. weight the child daily d. administer vitamin supplements
c. weight the child daily
The mother of a 9 month old who was diagnosed with respiratory syncytial virus yesterday calls the clinic to inquire if it will be all right to take her infant to the first b-day party of a friend's child the following day. What response should the nurse provide this mother? a. The child will no longer be contagious, no need to take any further precaution b. Make sure there are not children under the age of 6 months around the infected child c. The child can be around other children but should wear mask at all times d. Do not expose other children to RSV. It is very contagious even without direct contact
d. Do not expose other children to RSV. It is very contagious even without direct contact
the nurse observes a mother giving her 11 month-old ferrous sulfate, followed by two ounces of orange juice. What should the nurse do next? a. suggest placing the iron drops in the orange juice and feed the infant b. Tell the mother to follow the iron drops with formula instead of orange juice c. instruct the mother to feed the infant nothing in the next 30 minutes after the iron d. Give positive feedback about the way she administered the sulfate
d. Give positive feedback about the way she administered the sulfate
A 6 year old who has asthma is demonstrating a prolonged expiratory phase and wheezing and has a35% of personal best peak expiratory flow rate (PEFR) based on these finding, actions should the nurse take first? a. Administer a prescribed bronchodilator b. Encourage the child to cough and deep breath c. Report findings to the health care provider d. determine what triggers precipitated this attack
a. Administer a prescribed bronchodilator
