Pediatrics Nursing Care 3
A nurse is preparing to administer diphenhydramine 5mg/kg/day PO to divide equally every 8 hours to a school-aged child who weighs 50 lbs. Available is diphenhydramine oral solution 12.5 mg/5 mL. How many mL should the nurse administer per dose? (round to the nearest whole number)
15
A nurse is teaching the parents of a 4-month-old who has gastroesophageal reflux. Which of the following statements by the parents indicates an understanding of the teaching? A. "I will add 1 teaspoon of rice cereal per ounce to my baby's formula." B. "I will place my baby on her side when sleeping." C. "I will decrease the number of feedings my baby receives per day." D. "I will give my baby loperamide with each feeding."
A. "I will add 1 teaspoon of rice cereal per ounce to my baby's formula." Rationale: The parents can give the infant thickened feedings with rice cereal to help decrease the reflux. In addition, the added calories can help those infants who are underweight due to the gastroesophageal reflux.
A nurse at a clinic is preparing to adminster immunizations to a 5-year-old child. Which of the following immunizations should the nurse plan to give? A. Diphtheria, tetanus, and pertussis (DTaP) B. Pneumococcal (PCV) C. Haemophilus influenza type B (Hib) D. Hepatitis B (Hep B)
A. Diphtheria, tetanus, and pertussis (DTaP) Rationale: Children should receive booster doses of the DTaP immunization between the ages of 4 and 6. It is around this age that blood titers drop due to decreasing antibodies.
A school nurse is assessing a child who has been stung by a bee. The child's hand is swelling and the nurse notes that the child has allergies to insect bites. Which of the following should the nurse expect if the child develops anaphylaxis? (Select all that apply) A. Bradycardia B. Nausea C. Hypertension D. Urticaria E. stridor
B, D, E Rationale: Nausea is correct. A common gastrointestinal response to excessive histamine release is nausea; Urticaria is correct. A common skin manifestation of excessive histamine release is hives, also known as urticaria; Stridor is correct. A serious, life-threatening response to excessive histamine release is airway narrowing, which presents as dyspnea and stridor.
A nurse is admitting a child who has acute lymphocytic leukemia. Which of the following lab values should the nurse expect? A. Platelet count 500,000 mm3 B. RBC 2.5 million/uL C. WBC 4,000/mm3 D. Hct 60%
B. RBC 2.5 million/uL Rationale: An RBC of 2.5 million/uL is below the expected reference range. A child who has acute lymphocytic leukemia has a low RBC.
A nurse is teaching a parent of an infant who has a colostomy. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will not dress my child in one-piece outfits." B. "I need to buy diapers that are tighter than my infant usually wears." C. "I need to apply paste to the back of the wafer on my child's appliance." D. "I will not need to toilet train my child."
C. "I need to apply paste to the back of the wafer on my child's appliance." Rationale: The parent should apply stoma paste to the back of the wafer on the appliance, as well as around the stoma, to act as a sealant to prevent skin breakdown.
A nurse is preparing to administer acetaminophen 240 mg PO daily to child who has a temperature of 102 F. The amount available is acetaminophen oral solution 160 mg/5mL. How many mL should the nurse administer per dose? (round to nearest tenth)
7.5
A nurse is preparing to administer and intramuscluar injection to a 2-month-old infant. In which of the following sites should the nurse plan to inject the infant? A. Vastus lateralis B. Dorsogluteal C. Deltoid D.Abdomen 5 cm (2 in) from the umbilicus
A. Vastus lateralis Rationale: The vastus lateralis is a large, developed muscle, even in an infant. The muscle can tolerate the volume of the injection, and there are no important nerves or blood vessels in this muscle.
A nurse is teaching a school-aged child who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements should the nurse make? A. "If you take too much insulin, drink a sugar-free cola." B. "You will need to decrease your insulin dosage when you become a teenager." C. "You can use a vial of insulin for up to 30 days." D. "Stop taking your insulin if you are vomiting."
C. "You can use a vial of insulin for up to 30 days." Rationale: The child can use an opened vial of insulin for 28 to 30 days stored at room temperature or in the refrigerator.
A nurse is teaching a school-aged child who is about to undergo a bone marrow aspiration. Which of the following statements should the nurse make? A. "I will give you an antibiotic before your procedure." B. "I will place you on your side during the procedure." C. "You might have a headache following the procedure." D. "I will place a pressure dressing over the area following the procedure."
D. "I will place a pressure dressing over the area following the procedure." Rationale: Applying a pressure dressing over the area following the procedure helps to prevent bleeding from the site.
A nurse if teaching a group of parents of adolescents about developmental needs. Which of the following statements by a parent should the nurse investigate further? A. "My child has frequent mood swings." B. "My child has a very messy bedroom." C. "My child takes 1 to 2 showers per day." D. "My child spends 4 hours per day in Internet chat rooms."
D. "My child spends 4 hours per day in Internet chat rooms." Rationale: Adolescents might spend time using a computer, but parents should know what they are doing, who they are communicating with, and limit the time. The American Academy of Pediatrics guidelines recommend 2 hr of screen time daily.
A nurse is caring for a 2-year-old child who has frequent highlight Urinary tract infections. When educating the parents on frequent urinary tract infections, Which of the following instructions should the nurse include in the teaching? A. Teach the child to wipe from front to back. B. Give the child frequent bubble baths. C. Urge the child to urinate every 6 hr. D. Administer oxybutynin daily.
A. Teach the child to wipe from front to back. Rationale: The child should be taught to wipe from front to back because this prevents bacterial contamination from the anal area entering the urethra.
A nurse is caring for a child who has acute glomerulonephritis. Which of the following actions should the nurse take? A. Maintain the child on strict bed rest. B. Check the child's blood pressure every 4 hr. C. Administer albumin to the child every 8 hr. D. Provide the child with a low-carbohydrate diet.
B. Check the child's blood pressure every 4 hr. Rationale: The nurse should check the child's blood pressure every 4 to 6 hr to monitor for hypertension.
A nurse is providing post-operative teaching to the parents of a 3-month-old infant who is recovering from an umbilical hernia repair. Which of the following statements by the parents indicate and understanding of the teaching? A. "I will expect the site to bulge when my baby cries." B. "I will place a belly band around my child's abdomen." C. "I will fold my baby's diaper away from the incision." D. "I will bathe my child in the bath tub daily."
C. "I will fold my baby's diaper away from the incision." Rationale: To prevent infection, the parent should be able to verbalize and demonstrate proper folding of the diaper to protect the surgical incision from contamination.
A nurse is caring for a 2-day-old infant who has myleomeningocele. Which of the following actions should the nurse make? A. Monitor the infant's head circumference. B. Position the infant supine. C. Place the infant under a radiant warmer. D. Tape a piece of plastic over the protruding membranes.
A. Monitor the infant's head circumference. Rationale: Infants who have myelomeningocele have an increased risk for hydrocephalus. Measuring the infant's head circumference helps to determine any increase.
A nurse is teaching the parents of a child who has rheumatic fever. Which of the following statements by the parents indicates and understanding of the teaching? A. "My child may take aspirin for his joint pain." B. "My child will need a blood transfusion prior to discharge." C. "I will need to wear a gown when in my child's room." D. "I will apply lotion to my child's peeling hands."
A. "My child may take aspirin for his joint pain." Rationale: Children who have rheumatic fever might take salicylates (aspirin) to control the inflammatory process that occurs in the joints.
A nurse is caring for a child who is receiving treatment for diabetic ketoacidosis and has a current blood glucose level of 250 mg/dL. Which of the following actions should the nurse take? A. Administer 5% dextrose in 0.9% sodium chloride by continuous IV infusion. B. Give potassium as a rapid IV bolus. C. Administer 3 units of ultralente insulin subcutaneously. D. Obtain an HbA1c level stat.
A. Administer 5% dextrose in 0.9% sodium chloride by continuous IV infusion. Rationale: When the child's blood glucose level falls between 250 and 300 mg/dL, the nurse should begin IV infusion of 5% or 10% dextrose in 0.9% sodium chloride. The goal is to maintain blood glucose levels between 120 and 240 mg/dL. If dextrose is not added, hypoglycemia might occur.
A nurse is caring for a child who has been in Bucks traction for 2-days. which of the following actions should the nurse take to prevent complications? A. Check for pulses in the affected leg every 4 hr. B. Cleanse the pins every 12 hr. C. Inform parents to discourage visitors for the child. D.Manually move the weights to the floor when the child is experiencing pain.
A. Check for pulses in the affected leg every 4 hr. Rationale: Traction might lead to neurovascular compromise. The nurse should assess for edema, pulses, pain, color, and temperature of the extremity every 4 hr.
A nurse is planning care for a pre-school child who has autism and is being admitted to the facility. Which of the following actions should the nurse plan to take? A. Encourage the parents to bring in the child's stuffed animal. B. Give the child choices when planning daily activities. C. Administer phenytoin three times per day. D.Provide a shared room with another child his age.
A. Encourage the parents to bring in the child's stuffed animal. Rationale: Encouraging parents to bring in a child's favorite stuffed animal helps lessen the disruptiveness of hospitalization.
a school nurse is assessing an adolescent child who is returning to school following mono. The child has a note from their provider dismissing them from participating in gym. Which of the following reasons should the nurse recognize as the reason for this? A. Potential for sustaining abdominal trauma B. Deficient dietary intake C. Exposing peers to the illness D. Straining sore joints
A. Potential for sustaining abdominal trauma Rationale: An adolescent who has mononucleosis will have lymphadenopathy and often splenomegaly, which can persist for many months. For this reason, even after the adolescent is able to maintain his usual energy level and return to school, it is important for him to avoid activities that might result in trauma to the enlarged spleen.
A nurse is preparing a school-aged child for a tonsillectomy. Which of the following actions should the nurse take? A. Schedule the child for a preoperative visit to the facility. B. Inform the child he will be put to sleep during the procedure. C. Read the child a story about a cartoon character having a similar operation. D. Tell the child the appointment is to have his throat checked.
A. Schedule the child for a preoperative visit to the facility. Rationale: A preoperative visit to the facility allows the child to observe perioperative processes. This education helps the child feel at ease prior to the surgical procedure.
A nurse is caring for a group of infants that have congenital heart defects. For which of the following defects should the nurse expect to observe cyanosis? A. Transposition of great arteries B. Ventricular-septal defect C. Coarctation of the aorta D. Patent-ductus arteriosus
A. Transposition of great arteries Rationale: An infant who has transposition of great arteries will have severe cyanosis because reversal of the anatomic position of the aorta and pulmonary artery allows venous blood to enter the systemic circulation without oxygenation.
A nurse is reviewing the medical record of a 2-month-old infant who has rotavirus. The nurse notes a hemoglobin level of 12 g/dL and a hematocrit of 51%. Which of the following statements by the nurse indicates an understanding of the laboratory values? A."The infant might be dehydrated." B. "The infant might be anemic." C. "The infant might have received too much fluid." D. "The infant might have leukemia."
A."The infant might be dehydrated." Rationale: An increased hematocrit level indicates dehydration. Hematocrit levels rise when blood volume is decreased during dehydration.
A nurse is teaching parents of a 10-year-old child who has iron deficiency anemia. Which of the following statements by the parents indicates an understanding of the teaching? A. "I will give my child an iron tablet once each day at bedtime." B. "I will administer the iron tablet with orange juice." C. "I will encourage my child to take an antacid with the iron tablet." D. "I will crush the iron tablet prior to giving it to my child."
B. "I will administer the iron tablet with orange juice." Rationale: The intake of citrus juices with the iron will increase the iron's absorption.
A nurse is teaching the parents of a 3-year-old child who has persistent otitis medias about prevention. Which of the following statements by the parents represents an understanding of the teaching? A. "My child should not play around others who have ear infections." B. "We should not smoke around our child." C. "My child should not swim this summer." D. "I will encourage my child to blow his nose forcefully when he has a cold."
B. "We should not smoke around our child." Rationale: Preventing exposure to tobacco smoke at home can prevent further episodes of ear infections because tobacco smoke can cause inflammation of the respiratory tract.
a nurse is caring for a 10-year-old child who should reduce fat intake. Which of the following menu choices should the nurse suggest? A. A hot dog on a whole wheat bun B. 3 oz of baked chicken on a whole wheat roll C. 1/2 cup diced potatoes with scrambled eggs D. A medium blueberry muffin
B. 3 oz of baked chicken on a whole wheat roll Rationale: A baked chicken sandwich on a whole wheat bun has the lowest fat content at 6.2 g.
A nurse is caring for a child who is in the emergency department after ingesting a bottle of acetaminophen. Which of the following medication should the nurse plan to administer? A. Digoxin immune fab B. Acetylcysteine C.Naloxone D. Vitamin K
B. Acetylcysteine Rationale: Acetylcysteine is the antidote for acetaminophen overdose or poisoning.
A nurse is caring for a child who adheres to a vegetarian diet and has sustained superficial partial-thickness burns. The nurse should recommend which of the following food choices as having the highest protein content? A. Medium baked potato B. Wheat bagel with 1 tbsp of apricot jam C. Large orange D. 1/2 cup of peanut butter with apple slices
D. 1/2 cup of peanut butter with apple slices Rationale: Peanut butter and apple slices have a total of 28.91 g of protein. This is a good choice for this client because peanut butter is high in protein, which helps with the healing process.
A nurse is caring for a 4-year-old child who has pneumonia. The child's mother left 2 hours ago and he is currently experiencing the separation anxiety stage of despair. Which of the following findings should the nurse expect? A. Crying and screaming B. Inactive and thumb sucking C. Shows interest in toys around him D. Attempts to escape and find parent
B. Inactive and thumb sucking Rationale: A child who is sucking his thumb and refusing to eat or drink is displaying manifestations of the second stage of separation anxiety, which is despair.
a nurse is caring for a pre-school aged child who has mucosal ulceration after receiving chemotherapy. Which of the following actions should the nurse take? A. Place viscous lidocaine on the child's oral lesions. B. Instruct the child to use a soft sponge toothbrush when brushing her teeth. C. Encourage the child to mouth rinse with hydrogen peroxide every 2 to 4 hr. D. Children who have mucosal ulcerations should avoid the use of lemon glycerin swabs because they are very irritating, especially on eroded tissues.
B. Instruct the child to use a soft sponge toothbrush when brushing her teeth. Rationale: The child should use a soft sponge toothbrush when brushing her teeth because a regular toothbrush might cause further irritation to the mucosal ulcers.
A nurse is caring for a child who has an exacerbation of cystic fibrosis. Which of the following lab values should the nurse tell the provider about immediately? A. Blood glucose 140 mg/dL B. Oxygen saturation 85% C. RBC 3.2 million/uL D.Serum sodium 156 mEq/L
B. Oxygen saturation 85% Rationale: 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. 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. Therefore, the nurse should report this finding to the provider immediately.
A nurse is caring for a 4-year-old child who has superficial partial- thickness burns over 50% of his body. when planning for the nutritional needs of the child, which of the following actions should the nurse plan to make? A. Administer pancrelipase to the child prior to each meal. B. Supplement the child's feedings with enteral feedings. C. Provide the child with a low-protein meal. D. Perform dressing changes 10 min prior to the child's meals.
B. Supplement the child's feedings with enteral feedings. Rationale: A child who has burns in excess of 25% of total body surface area requires enteral supplementation to consume enough calories to heal.
A nurse is teaching about posioning prevention to a group of parents who have toddlers. Which of the following statements should the nurse make? A. "Keep medications on a counter that is out of reach of the toddler." B. "Do not allow live plants in the house." C. "Put all cleaning supplies in a locked cabinet." D. "Allow your child to eat from his favorite ceramic bowls."
C. "Put all cleaning supplies in a locked cabinet." Rationale: Parents should lock up cleaning supplies to provide for the safety of toddlers. Toddlers are very inquisitive and are able to open most cabinet doors without difficulty. The toddler cannot open the door of a locked cabinet.
A nurse is teaching the parents of a child who has cerebral palsy. Which of the following statements should the nurse make? A. "Your child will be unable to eat by mouth." B. "Your child will be unable to participate in recreational activities." C. "Your child will need a botulinum toxin A injection to help with muscle spasticity." D. "Your child will need throw rugs placed over non-carpeted areas."
C. "Your child will need a botulinum toxin A injection to help with muscle spasticity." Rationale: Children who have cerebral palsy have spasticity in their muscles. The child can receive botulinum toxin type A injections into affected muscles, which aid in reducing the spasticity.
A nurse is caring for a school-aged child who has glomerulonephritis. The child has decreased urinary output, a blood pressure of 160/78 mm Hg, and is receiving hydralazine. Which of the following lunch choices should the nurse recommend? A. 1 hot dog, 22 potato chips, and 120 mL (4 oz) of orange juice B. 1 sandwich with lettuce, tomato, and 4 slices bacon, a small apple, and 240 mL (8 oz) of milk C. 3 oz grilled chicken, 1 cup of pear slices, and 120 mL (4 oz) of apple juice D. 1 cup of cottage cheese, a small banana, and 240 mL (8 oz) of soda
C. 3 oz grilled chicken, 1 cup of pear slices, and 120 mL (4 oz) of apple juice Rationale: The child who has glomerulonephritis has moderate restriction of sodium and further restriction is given to foods high in potassium with children who have decreased urinary output. These restrictions are because the kidneys of these children are not functioning appropriately. This diet is the lowest option and consists of 571 g of potassium and 268 g of sodium.
A nurse is teaching the parents of an infant who has congenital hypothyroidism. Which of the following statements should the nurse make? A. "Your child will need to take estrogen daily when she reaches puberty." B. "Your child will need monthly blood coagulation studies." C. "Your child will need surgery to remove the diseased thyroid." D. "Your child will need to take thyroid hormone replacement for her entire life."
D. "Your child will need to take thyroid hormone replacement for her entire life." Rationale: In congenital hypothyroidism, the child does not manufacture an adequate amount of thyroid hormone to maintain the appropriate metabolic rate. The child will require life-long thyroid hormonal replacement for normal growth and development.
A nurse on the pediatric unit is caring for a group of clients. Which of the following findings should be the nurses priotity? A. A child who has asthma and a pulse oximetry of 94% B. A child who has nephrotic syndrome and 1+ protein on the urine dipstick C. A child who has sickle cell anemia and a urine specific gravity of 1.030 D. A child who has insulin-dependent diabetes mellitus and a fingerstick glucose reading of 110 mg/dL
C. A child who has sickle cell anemia and a urine specific gravity of 1.030 Rationale: 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. 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 child who has sickle cell anemia must maintain adequate hydration because dehydration might cause sickle cell crisis that can occlude the child's circulation.
A nurse is caring for a 4-month-old child who has acute otitis media and a fever of 38.3 C (101 F). Which of the following medications should the nurse administer? A. Diphenhydramine B. Furosemide C. Amoxicillin D. Ibuprofen
C. Amoxicillin Rationale: A child who has acute otitis media should take an antibiotic to help alleviate the infection.
A nurse is caring for a child who has epistaxis. Which of the following actions should the nurse take? A. Apply a warm cloth to the bridge of the child's nose. B. Tilt the child's head back. C. Apply continuous pressure to the child's nose for at least 10 min. D. Administer aspirin for the child's pain.
C. Apply continuous pressure to the child's nose for at least 10 min. Rationale: The nurse needs to apply continuous pressure for at least 10 minutes to help stop bleeding.
A nurse is caring for a toddler who has asthma. the parents are concerned about the toddlers reaction to hospitalization. Which of the following actions should the nurse take to decrease the childs anxiety? A. Provide privacy. B. Give the child a thorough explanation before providing care. C. Encourage rooming-in. D. Tell the child you will help fix her.
C. Encourage rooming-in. Rationale: Rooming-in is the most effective means of providing emotional support for a toddler. The family's presence provides a sense of security that increases the child's ability to cope in an unfamiliar environment.
a nurse is assessing the pain level of a 3-year-old child who is postoperative following abdominal surgery. Which of the following pain scales should the nurse use? A. Word graphic rating scale B. Color tool C. FACES pain rating scale D. Numeric scale
C. FACES pain rating scale Rationale: The FACES scale is a scale that looks at various faces, which represent various levels of pain. A 3-year-old child is able to identify faces that represent different pain levels.
A nurse is caring for an 8-year-old child who has sickle cell anemia. Which of the following actions should the nurse take? A. Apply cool compresses to the painful area. B. Initiate contact isolation precautions. C. Give the child flavored popsicles. D. Administer phytonadione.
C. Give the child flavored popsicles. Rationale: Maintaining hydration with a child who has sickle cell anemia is important to prevent sickling. Children accept flavored popsicles as a source of fluid.
A nurse is caring for a 6-month-old who has intussusception. Which of the following actions should the nurse take? A. Prepare to administer high-dose steroids. B. Give the child magnesium hydroxide PO. C. Prepare the child for a barium enema. D.Educate the parents that the child will need a colostomy.
C. Prepare the child for a barium enema. Rationale: The pressure created by a barium enema might force the bowel to resume a normal configuration. Some children are treated with the barium enema and do not require surgical intervention.
A nurse is teaching a group of parents of toddlers about growth and development. A parent asks, "Why does my child's abdoment stick out?" Which of the following statements should the nurse make? A. "You should give your child a stool softener daily." B. "Toddlers gain weight at a rapid pace." C. "You should have your child assessed for a spinal deformity." D. "Toddlers do not have well-developed abdominal muscles."
D. "Toddlers do not have well-developed abdominal muscles." Rationale: The abdominal muscles are immature and not well developed at this stage. Therefore, it is common for a toddler to have a "potbellied" appearance.
A nurse is assessing an adolescent who has sustained a broken tibia. Following the application of a fiber glass cast, the adolescent reports pain and a tingling feeling in the limb. Which of the following actions should the nurse take first? A. Give the adolescent ibuprofen. B. Elevate the adolescent's leg on pillows. C. Place an ice pack on the cast. D. Assess for manifestations of circulatory impairment.
D. Assess for manifestations of circulatory impairment. Rationale: 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. 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. Therefore, the nurse should first assess for circulatory impairment to ensure there is no vascular compromise.
a nurse is planning care for a 6-year-old child who is receiving chemotherapy. the child has a highlight platelet count of 20,000/mm cubed. Based on this lab value, which of the following interventions should the nurse include in the plan of care? A. Provide foods high in iron. B. Avoid people who have infections. C. Administer PRN oxygen. D. Encourage quiet play.
D. Encourage quiet play. Rationale: A platelet count of 20,000/mm3 will predispose the client to excessive bleeding. Quiet play will lessen the client's risk for injury, thereby reducing the chance of hemorrhage.
A nurse is caring for a child who has cystic fibrosis and a pulmonary infection. Which of the following findings is the nurses priority? A. Blood streaking of the sputum B. Dry mucous membranes C. Constipation D. Inability to clear secretions
D. Inability to clear secretions Rationale: 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. 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. Therefore, the inability to clear secretions is the priority-finding because the child has a compromised airway and the nurse must act in a manner that ensures transportation of oxygen to the body's cells.
A nurse is caring for a child who has teratology of fallout. Which of the following lab values should the nurse expect to find? A. Platelet count of 20,000/mm3 B. WBC 4,000/mm3 C. Thyroid stimulating hormone 7.0 microunits/mL D. RBC 6.8 million/uL
D. RBC 6.8 million/uL Rationale: A child who has Tetralogy of Fallot causes cyanosis; therefore, the body responds by increasing RBC production (polycythemia) in an attempt to supply oxygen to all body parts.
A nurse is caring for a child who has suspected nephrotic syndrome. Which of the following laboratory values should the nurse expect? A. Platelet count 120,000/mm3 B. Serum sodium 160 mEq/L C. Hgb 9 g/dL D. Serum cholesterol 700 mg/dL
D. Serum cholesterol 700 mg/dL Rationale: A serum cholesterol level of 700 mg/dL is above the expected reference range. A child who has nephrotic syndrome will have high serum cholesterol findings because of the increase in plasma lipids.
A nurse is caring for a child who has a vesicular rash. The parents of the child asks the nurse what can cause this rash for 6 days. The nurse should expect that the child has which of the following conditions? A. Measles B. Fifth disease C. Tetanus D. Varicella
D. Varicella Rationale: Children who have varicella might commence with a maculopapular rash that progresses to vesicles on erythematous bases that eventually rupture and crust over.
