ATI Peds ATI 2019 B with NGN/rationales

A nurse is caring for a school age child who has primary nephrotic syndrome and is taking prednisone. Following 1 week of treatment, which of the following manifestations indicates to the nurse that the medication is effective? a. decreased edema b. increased abdominal girth c. decreased appetite d. increased protein in the urine

A A child who has nephrotic syndrome can experience edema due to the increased glomerular permeability, which increases protein loss. Prednisone decreases glomerular permeability, which causes fluid to shift from the extracellular spaces, resulting in decreased edema. The nurse should expect decreased abdominal girth with prednisone therapy. Increased, rather than decreased, appetite is an expected manifestation of corticosteroid therapy. The nurse should expect decreased protein in the urine with prednisone therapy.

A nurse is reviewing the laboratory results of a school age child who is 1 week postoperative following an open fracture repair. Which of the following findings should the nurse identify as an indication of a potential complication? a. erythrocyte sedimentation rate 10mm/hr b. WBC count 6200/mm^3 c. c-reactive protein 1.4mg/L d. RBC count 4.7 million/mm^3

A Erythrocyte sedimentation rate 18 mm/hrMY ANSWERThe nurse should identify that an erythrocyte sedimentation rate of 18 mm/hr is above the expected reference range of up to 10 mm/hr and is an indication of osteomyelitis. WBC count 6,200/mm3The nurse should identify that a WBC count of 6,200/mm3 is within the expected reference range of 5,000 to 10,000/mm3. An elevated WBC count is an indication of osteomyelitis. C-reactive protein 1.4 mg/LThe nurse should identify that a C-reactive protein level of 1.4 mg/L is within the expected reference range of less than 10.0 mg/L. An elevated C-reactive protein level is an indication of osteomyelitis. RBC count 4.7 million/mm3The nurse should identify that an RBC count of 4.7 million/mm3 is within the expected reference range of 4.0 to 5.5 million/mm3. A decreased RBC count can indicate hemorrhage.

A nurse is assessing an infant who has pneumonia. Which of the following findings is the priority for the nurse to report the provider? a. nasal flaring b. WBC count 11,300/mm^3 c. diarrhea d. abdominal distension

A Nasal flaringMY ANSWERWhen using the airway, breathing, and circulation approach to client care, the nurse should determine that the priority finding to report to the provider is nasal flaring. Nasal flaring indicates the infant is experiencing acute respiratory distress. WBC count 11,300/mm3The nurse should report a WBC count of 11,300/mm3 because it is above the expected reference range of 5,000 to 10,000/mm3 and indicates infection. However, there is another finding that is the priority for the nurse to report. DiarrheaThe nurse should report diarrhea because it is a manifestation of pneumonia in infants and indicates the current treatment is not effective. However, there is another finding that is the priority for the nurse to report. Abdominal distensionThe nurse should report abdominal distension because it is a manifestation of pneumonia in infants and indicates the current treatment is not effective. However, there is another finding that is the priority for the nurse to report.

A nurse is creating a plan of care for a preschooler who has Wilms' tumor and is scheduled for surgery. Which of the following interventions should the nurse include? a. avoid palpating the abdomen when bathing the child before surgery b. refrain form auscultating the child's bowel sounds during the postoperative assessment c. encourage the child to play with other children on the unit prior to surgery d. explain to the child that their pain will be managed after the surgery

A The nurse should avoid palpating the abdomen when bathing the child before surgery because the movement of the tumor can cause cancer cells to disseminate to other sites, adjacent and distant to the tumor site. Auscultation of the child's bowel sounds to monitor for obstruction is an important part of the postoperative assessment. Therefore, the nurse should auscultate bowel sounds following the surgery. The child's risk for injury increases with physical activity. Therefore, the nurse should not encourage the child to play with other children on the unit. Telling the child about pain prior to surgery will likely increase their fear and anxiety level. Therefore, the nurse should not explain to the child that pain will be managed after surgery.

A nurse is caring for a school age child who has diabetes mellitus and was admitted with a diagnosis of diabetic ketoacidosis. When performing the respiratory assessment, which of the following findings should the nurse expect? a. deep respirations of 32/min b. shallow respirations of 10/min c. paradoxic respirations of 26/min d. periods of apnea lasting for 20 seconds

A The nurse should expect Kussmaul respirations in a child who has diabetic ketoacidosis. These deep and rapid respirations are the body's attempt to eliminate excess carbon dioxide and achieve a state of homeostasis. The nurse should expect shallow respirations in a child who has respiratory depression related to opioid administration. However, shallow respirations are not an expected finding in a child who has ketoacidosis. The nurse should expect paradoxic respirations in a child who has flail chest. However, paradoxic respirations are not an expected finding in a child who has ketoacidosis. The nurse should expect periods of apnea lasting 20 seconds or more in a child who has sleep apnea. However, periods of apnea are not an expected finding in a child who has ketoacidosis.

A nurse in a health department is caring for an emancipated adolescent who has an STI and is unaccompanied by a guardian. Which of the following actions should the nurse take? a. have the adolescent sign a consent form for treatment b. instruct the adolescent to return with a guardian c. obtain consent from the adolescent's guardian over the phone d. treat the adolescent without a consent form

A The nurse should identify that an emancipated minor can sign the consent form for treatment of an STI or any other form of medical treatment requiring consent. Adolescents or emancipated minors can provide their own consent for any medical treatment.

A nurse is teaching a group of parents about infectious mononucleosis. Which of the following statements by a parent indicates an understanding the teaching? a. "Mononucleosis is caused by an infection with the Epstein-Barr virus." b. "Mononucleosis is a bacterial infection requiring 14 days of antibiotics." c. "A monospot is a throat culture used to diagnosis mononucleosis." d. "Children who get mononucleosis will need to refrain form sports for 6 months."

A The nurse should identify that mononucleosis is a mildly contagious illness that occurs sporadically or in groups, and is primarily caused by the Epstein-Barr virus. The nurse should identify that infectious mononucleosis is caused by the Epstein-Barr virus. No known specific treatment is available for mononucleosis. The nurse should identify that a Monospot is a blood test that uses a special piece of paper to assist in diagnosing mononucleosis. The nurse should identify that a child who has mononucleosis should adjust their activities according to their level of fatigue. It is recommended that contact sports be avoided for about 4 weeks, or until splenomegaly has resolved.

A nurse is providing teaching to the parents of a preschooler who has heart failure and a new prescription for digoxin twice daily. Which of the following instructions should the nurse include in the teaching? a. "Use a kitchen teaspoon to measure the medication." b. "Brush the child's teeth after giving the medication." c. "double the next dose if the child misses a dose." d. "repeat the dose if the child vomits."

B The nurse should instruct the parents to brush the child's teeth after administering digoxin to prevent tooth decay caused by the medication, which comes as a sweetened liquid to enhance the taste.

A nurse is teaching the guardian of a 6 month old infant about teething. Which of the following statements should the nurse make? a. "your baby might pull at their ears when they are teething." b. "rub your baby's gums with an aspirin to decrease discomfort." c. "place a beaded teething necklace around your baby's neck." d. "Your baby's upper middle teeth will erupt first."

A The nurse should inform the guardian that teething can result in discomfort for the infant. Therefore, the guardian should look for indications such as pulling on the ears, difficulty sleeping, increased drooling, or increased fussiness. The guardian should avoid using aspirin or teething powders due to the risk of aspiration, infection, or irritation of the gum tissues. The nurse should recommend cold teething rings or gently rubbing the infant's gums with a cold cloth to minimize discomfort. Necklaces can result in suffocation and choking. Therefore, the nurse should instruct the guardian to avoid placing these on the infant. The nurse should inform the guardian that the eruption of an infant's teeth begins with the lower central incisors.

A nurse is caring for a school age child who has peripheral edema. The nurse should identify that which of the following assessments should be performed to confirm peripheral edema? a. palpate the dorsum of the child's feet b. weigh the child daily using the same scale c. assess the child's skin turgor d. observe the child for periorbital swelling

A The nurse should palpate the dorsum of the feet by pressing the fingertip against a bony prominence for 5 seconds to assess for peripheral edema. Weighing the child daily might indicate that the child has retained fluid. However, this is not a method the nurse should use to assess for peripheral edema. Assessing the child's skin turgor measures the elasticity and mobility of the skin. However, this is not a method the nurse should use to assess for peripheral edema. Observing the child for periorbital swelling is a method used to assess for generalized edema. However, this is not a method the nurse should use to assess for peripheral edema.

A nurse is caring for an infant who is receiving IV fluids for the treatment of Tetralogy of Fallot and begins to have a hypercyanotic spell. Which of the following actions should the nurse take? a. place the infant in a knee-chest position b. administer a dose of meperidine IV c. discontinue administration of IV fluids d. apply oxygen at 2L/min via nasal cannula

A The nurse should place the infant in a knee-chest position during a hypercyanotic spell to decrease the return of desaturated venous blood from the legs and to direct more blood into the pulmonary artery by increasing systemic vascular resistance. The nurse should administer morphine IV to the infant, instead of meperidine, to decrease infundibular spasms that cause a decrease in pulmonary blood flow and right-to-left shunting. The nurse should continue the administration of IV fluids during a hypercyanotic spell to decrease the viscosity of the infant's blood, which decreases the risk of a cerebrovascular accident. The nurse should apply oxygen at 100% via face mask to assist with dilation of the pulmonary artery and improve oxygen supply to the brain.

A nurse is planning developmental activities for a newly admitted 10 year old child who has neutropenia. Which of the following actions should the nurse plan to take? a. provide the child with a book about adventure b. arrange frequent visits from family members and peers c. give the child a large piece puzzle d. use puppets to entertain the child

A The nurse should provide a school-age child with a book about adventure as a developmental activity because children are expanding their knowledge and imagination during this age. Through reading, school-age children can feel powerful and skillful as they imagine themselves in the stories they read. The nurse should limit visitors for a child who has neutropenia because this places the child at an increased risk for infection. The nurse should provide a large-piece puzzle to a preschooler. School-age children tend to be challenged mentally with complex board and video games. The nurse should use puppets to entertain toddlers. School-age children are not typically entertained for very long or challenged mentally with puppets. Instead, they tend to prefer complex board and video games.

A nurse is assessing the pain level of a 3 year old toddler. Which of the following assessment scales should the nurse use? a. FACES b. Numeric c. CRIES d. Visual analog

A The nurse should use the FACES pain rating scale for pediatric clients who are 3 years old and older. This scale allows the toddler to point to the face that depicts their current level of pain. The nurse can then determine the need for pain management.

A nurse is planning an educational program for school age children and their parents about bicycle safety. Which of the following information should the nurse plan to include? a. the child should be able to stand on the balls of their feet when sitting on the bike b. the child should ride their bike 2 feet to the side of other bike riders c. the child should wear dark colored clothing with a fluorescent stripe when riding at night d. the child should ride the bike facing traffic when it is necessary to tide in the street

A To decrease the risk of injury, parents should ensure that the bike is the correct size for the child. When seated on the bike, the child should be able to stand with the ball of each foot touching the ground and should be able to stand with each foot flat on the ground when straddling the bike's center bar. To decrease the risk of injury, children should ride their bikes single file rather than side by side. To decrease the risk of injury when riding a bike at night, children should wear light-colored clothing that has fluorescent material attached. This measure, along with the fluorescent material on the bike itself, makes bike riders more visible to motor vehicle drivers and other bike riders. To decrease the risk of injury, bike riders should ride in the direction of the flow of traffic.

A nurse is receiving change of shift report for four children. Which of the following children should the nurse assess first? a. a toddler who has a concussion and an episode of forceful vomiting b. an adolescent who has infective endocarditis and reports having a headache c. an adolescent who was placed into halo traction 1 hr ago and reports pain as 6 on a scale of 0-10 d. a school age child who has acute glomerulonephritis and brown-colored urine

A When using the urgent vs. nonurgent approach to client care, the nurse should assess this child first. An episode of forceful vomiting is an indication of increased intracranial pressure in a toddler who has a concussion. A report of a headache is nonurgent because it is an expected finding for a child who has infective endocarditis. Therefore, the nurse should assess another child first. A report of moderate pain is nonurgent because it is an expected finding for a child who has a new halo traction device. Therefore, the nurse should assess another child first. Brown-colored urine is nonurgent because it is an expected finding for a school-age child who has acute glomerulonephritis. Therefore, the nurse should assess another child first.

A nurse is providing dietary teaching to the guardian of a school age child who has cystic fibrosis. Which of the following statements should the nurse make? a. "You should offer your child high protein meals and snacks throughout the day." b. "You should decrease your child's dietary fat intake to less than 10% of their caloric intake." c. "You should restrict your child's calorie intake to 1200 per day." d. "you should give your child a multivitamin once weekly."

A You should offer your child high-protein meals and snacks throughout the day. The nurse should instruct the guardian to provide a diet that is well-balanced and high in protein and calories. Children who have cystic fibrosis require a higher percentage of the recommended dietary allowances of all nutrients to meet their energy requirements. Children who have good nutritional intake have improved lung function and decreased risk of infection. They also require 35% to 40% of their calories to come from fats due to decreased absorption from the intestines. Children who have cystic fibrosis require a high-calorie diet and should consume at least 2,000 calories per day. Children who have cystic fibrosis should be given a multivitamin once daily.

A nurse is an emergency department is assessing a toddler who has Kawasaki disease. Which of the following findings should the nurse expect? (select all that apply.) a. increased temperature b. gingival hyperplasia c. xerophthalmia d. bradycardia e. cervical lymphadenopathy

A, C, E Kawasaki disease is an acute illness associated with a fever that is unresponsive to antipyretics or antibiotics. Children who have Kawasaki disease develop a strawberry tongue, cracked lips, and edema of the oral mucosa and pharynx. A child who is receiving phenytoin therapy can develop gingival hyperplasia. Ophthalmic manifestations of Kawasaki disease include reddening of the conjunctiva and dryness of the eyes, or xerophthalmia. Kawasaki disease is an infection that affects the vascular system, including the heart. The nurse should expect the child to be tachycardic with a gallop rhythm. Long-term effects of Kawasaki disease include the development of coronary artery aneurysms or myocardial infarction. A child who has Kawasaki disease can develop enlarged cervical nodes on one side of the neck that is nontender and greater than 1.5 cm in size.

A nurse on a pediatric unit is caring for a school-age child. Vital Signs 1230: Temperature 38.2° C (100.8° F)Heart rate 110/min Respiratory rate 20/min Blood pressure 90/60 mm Hg Pulse oximetry 97% 1330: Temperature 38.2° C (100.8° F)Heart rate 100/min Respiratory rate 22minPulse oximetry 92% Physical Examination Child is restless and crying. Swelling noted at hand joints. Capillary refill less than 3 seconds. Mucous membranes dry and sticky. Respirations regular and unlabored. Abdomen soft, flat, and non-distended. Tenderness with light palpation. Child reports pain as 8 on a scale of 0 to 10. Diagnostic Results CBC: Hemoglobin 8.0 g/dL (10 to 15.5 g/dL)Hematocrit 28% (32% to 44%) RBC count 4.2 million/mm3 (4 to 5.5 million/mm3)WBC count 12,000/mm3 (5,000 to 10,000/mm3)Platelets 350,000/mm3 (150,000 to 400,000/mm3) Reticulocyte count 3% (0.5% to 2%). Medical History Sickle cell anemia

After reviewing the information in the child's medical record, which of the following findings should the nurse address first? Oxygen saturation is correct. The child's pulse oximeter reading is below the expected reference range. The nurse should take action to maintain the child's oxygen saturation above 95%. When using the urgent vs. non-urgent approach to client care, the nurse should identify that addressing the child's hypoxia is the priority intervention. Pain is correct. The child reported their pain as 8 on a scale of 0 to 10, which indicates severe pain. Vaso-occlusive crises can cause severe pain due to tissue ischemia from sickled cells obstructing blood flow. When using the urgent vs. non-urgent approach to client care, the nurse should identify that addressing the child's pain is the priority after addressing the child's hypoxia.

A nurse on a pediatric unit is admitting a preschooler. Vital Signs 0715: Temperature 38.3° C (100.9° F) Heart rate 126/min Respiratory rate 26/min Pulse oximeter 97%. Physical Examination 0715: Guardians report that the child has been tired lately and has been experiencing a sore throat and fever. Child is tolerating sips of liquids, but is refusing solid foods. Guardians report that the child is voiding dark yellow urine. 0730: Child is alert and responsive to verbal stimuli. Mucous membranes are dry and sticky. Skin turgor without tenting. Tonsils enlarged and erythematous. Respirations are regular and non-labored. No accessory muscle use noted. Lungs clear anterior and posterior bilaterally. Point of maximum intensity (PMI) in left mid-clavicular line 4th intercostal space. Heart rate is regular without murmurs, gallops, or rubs. Radial and pedal pulse 2+ bilaterally. Capillary refill greater than 2 seconds.

After reviewing the information in the medical record, the nurse should identify that the child is at risk for developing which of the following conditions? Complete the following sentence by using the list of options. Splenomegaly is correct. The child's positive mononucleosis rapid test result indicates the presence of infectious mononucleosis, a condition caused by the Epstein-Barr virus. Therefore, the nurse should identify that the child is at risk for developing splenomegaly, a common complication of infectious mononucleosis. Positive mononucleosis rapid test is correct. The child's positive mononucleosis rapid test result indicates the presence of infectious mononucleosis, a condition caused by the Epstein-Barr virus. Therefore, the nurse should identify that the child is at risk for developing splenomegaly, a common complication of infectious mononucleosis.

A nurse is assessing a school age child who has an infratentorial brain tumor. Which of the following findings should the nurse identify as a manifestation of increased intracranial pressure? a. hypotension b. reports insomnia c. difficulty concentrating d. tachycardia

C The nurse should identify that hypertension is a late manifestation of increased intracranial pressure due to compression of the brain vessels. The nurse should identify that somnolence and lethargy are manifestations of increased intracranial pressure. The nurse should identify that irritability, inability to follow commands and difficulty concentrating are manifestations of increased intracranial pressure due to decreased blood flow within the brain and pressure on the brainstem. The nurse should identify that bradycardia is a late manifestation of increased intracranial pressure.

A nurse is providing teaching to an adolescent about how to manage tinea pedis. Which of the following statements by the adolescent indicates an understanding of the teaching? a. "I should buy plastic shoes to wear at the swimming pool." b. "I should wear sandals as much as possible." c. "I should place the permethrin cream between my toes twice daily." d. "I should seal my nonwashable shoes in plastic bags for a couple of weeks."

B "I should buy plastic shoes to wear at the swimming pool."The use of plastic shoes increases the occurrence of tinea pedis. The nurse should instruct the adolescent to avoid wearing plastic shoes. "I should wear sandals as much as possible."MY ANSWERSandals allow air to circulate around the feet, decreasing perspiration and eliminating the medium for bacteria and fungus to grow. The nurse should inform the adolescent that wearing sandals, open-toed, or well-ventilated shoes will promote healing of the fungal infection. "I should place the permethrin cream between my toes twice daily."Permethrin 5% cream is a scabicide used to treat scabies. This treatment is not indicated for tinea pedis. "I should seal my nonwashable shoes in plastic bags for a couple of weeks."Sealing nonwashable items in plastic bags for 14 days is a recommended practice for clients who have pediculosis. This practice is not indicated for tinea pedis.

A nurse is providing teaching to the family of a school-age child who has juvenile idiopathic arthrisis. Which of the following instructions should the nurse include in the teaching? a. "limit movement of the child's large joints" b. "encourage the child to perform independent self-care." c. "provide the child with a soft mattress for sleeping." d. "schedule a 2 hour daily nap for the child in the afternoon."

B "Limit movement of the child's large joints."Large joints should be exercised regularly to maintain mobility and strengthen muscles. "Encourage the child to perform independent self-care."MY ANSWERThe nurse should teach the family the importance of encouraging the child to perform independent self-care. This will minimize the child's pain while maximizing mobility. Encouraging and praising the child's efforts for independence will also increase their self-esteem. "Provide the child with a soft mattress for sleeping."Children who have juvenile idiopathic arthritis should sleep on a firm mattress to provide support in maintaining joints in a functional position. "Schedule a 2-hour daily nap for the child in the afternoon."Daytime naps are discouraged because stiffness can occur quickly and easily with inactivity, and naps can interfere with nighttime sleeping.

A nurse in an emergency department is caring for a school age child who has sustained a minor superficial burn from fireworks on their forearm. Which of the following actions should the nurse take? a. administer the tetanus toxoid vaccine if more than 1 year since the prior dose b. apply an antimicrobial ointment to the affected area c. leave the burn area open to air d. place an ice pack on the affected area

B Administer the tetanus toxoid vaccine if more than 1 year since the prior dose.The nurse should administer the tetanus toxoid vaccine if it has been more than 5 years since the prior dose. Apply an antimicrobial ointment to the affected area.MY ANSWERThe nurse should apply an antimicrobial ointment to the burned area to prevent infection. Leave the burn area open to air.The nurse should apply a clean-dry dressing of fine mesh gauze and a light gauze dressing that restricts movement to prevent injury to the wound. Place an ice pack on the affected area.Applying ice to the affected area can impair circulation to the area and increase tissue damage.

A nurse is caring for a toddler who has acute otitis media and a temperature of 40 degree C (104 degrees F). After administering acetaminophen, which of the following actions should the nurse plan to take to reduce the toddler's temperature? a. apply a cooling blanket to the toddler b. dress the toddler in minimal clothing c. give the toddler a tepid bath d. administer diphenhydramine to the toddler

B Apply a cooling blanket to the toddler.Applying a cooling blanket can cause shivering and discomfort, which increases metabolic requirements. The nurse should be aware that the use of a cooling blanket is indicated for the treatment of hyperthermia, but not a fever. Dress the toddler in minimal clothing.MY ANSWERThe nurse should recognize that dressing the toddler in minimal clothing will expose the skin to air and maximize heat evaporation from the skin, thus reducing the toddler's temperature. Give the toddler a tepid bath.A tepid bath is lukewarm, which can cause discomfort to the toddler. The nurse should be aware that the use of a tepid bath is indicated for the treatment of hyperthermia, but not a fever. Administer diphenhydramine to the toddler.Diphenhydramine is an antihistamine indicated for the treatment of an allergic reaction. The nurse should identify that antipyretics, such as acetaminophen, are indicated for the treatment of a fever.

A nurse is providing discharge teaching to the guardians of a toddler who had a lower leg cast applied 24 hours ago. The nurse should instruct the guardians to report which of the following findings to the provider? a. capillary refill time less than 2 seconds b. restricted ability to move the toes c. swelling of the casted foot when the leg is dependent d. pedal pulse +3 bilateral

B Capillary refill time is assessed to determine circulatory status by pressing lightly on the tips of the toes until the skin has blanched. A capillary refill time that is greater than 2 seconds indicates circulatory compromise and should be reported to the provider immediately. The nurse should inform the guardians that the restricted ability of the toddler to move their toes is an indication of neurovascular compromise and requires immediate notification to the provider. Permanent muscle and tissue damage can occur in just a few hours. Swelling of the casted foot when the leg is dependent is an expected finding. The nurse should instruct the guardians that frequent rest is needed for the next several days and that the casted foot should not be in a dependent position for more than 30 min. When the toddler is resting, the casted extremity should be elevated on a pillow at chest level to minimize swelling. A pulse that is not easily obliterated with pressure is graded as a +3 and is an expected finding that indicates adequate circulation of the extremity. An absent pulse indicates circulatory compromise and should be reported to the provider immediately.

A nurse is teaching a school age child and their parent about postoperative care following cardiac catheterization. Which of the following instructions should the nurse include? a. "Stay home from school for 1 week following the procedure." b. "follow a diet that is low in fiber for 1 week." c. "wait 3 days before taking a tub bath." d. "apply a pressure dressing to the site for 3 days."

C The child can attend school the next day but they should avoid strenuous activities to prevent bleeding at the insertion site. The child can resume their regular diet after the procedure. The child should keep the site clean and dry for at least 3 days to reduce the risk of infection. Tub baths should be avoided for 3 days to avoid immersion of the incision in water. The parent can remove the pressure dressing the day after the procedure and should apply a new adhesive bandage strip daily to the site for at least the next 2 days.

A nurse in an emergency department is caring for a school age child who has epiglottitis. Which of the following actions should the nurse take? a. obtain a throat culture form the child b. monitor the child's oxygen saturation c. put a warm mist humidifier in the child's room d. place the child in the supine position

B Obtaining a throat culture places the child at risk for complete airway obstruction. The nurse should wait until an airway is established for the child before performing any diagnostic testing. The nurse should monitor the child's oxygen saturation level because the child is experiencing acute respiratory distress and it is necessary to determine if the child is responding to treatment. The nurse should administer humidified oxygen by face mask or blow-by, rather than place a warm mist humidifier in the child's room. Placing the child in the supine position increases the child's risk for complete airway obstruction. The nurse should allow the child to be in whatever position they feel provides the most help with breathing. This is usually an upright position, and sometimes it is helpful for the child to lean forward to help with breathing.

A nurse is teaching the parents of a toddler who has a cognitive impairment about toilet training. Which of the following instructions should the nurse include in the teaching a. "scold your child when they have toileting accident." b. "award your child with a sticker when they sit on the potty chair." c. "play your child's favorite song while teaching them to use the potty chair." d. "teach multiple steps of the skill at the same time."

B Parents should use positive reinforcement when teaching their children a new task. Reinforcing positive behaviors, such as remaining dry through the night, will have a greater effect on the child than the negative reinforcement of scolding. A child who has a cognitive impairment learns through shaping behaviors. The parents should reward the child for sitting on the potty chair as a reinforcement of the desired behavior of continence. As the child repeats this action, the parents can gradually decrease this reward and then give rewards for the next step in the task, such as voiding while sitting on the potty chair. A child who has a cognitive impairment has difficulty discriminating between two or more cues or stimuli. The nurse should instruct the parents to eliminate all other stimuli when teaching the child the task of toilet training. Children who have a cognitive impairment have difficulty remembering multiple steps. The nurse should instruct the parents to teach them one step at a time to the child. The child should master each step before the parents introduce the next step.

A nurse is monitoring the oxygen saturation level of an infant using pulse oximetry. The nurse should secure the sensor to which of the following areas on the infant? a. wrist b. great toe c. index finger d. heel

B The nurse should avoid placing the sensor on the wrist because this placement will result in an inaccurate reading. The nurse should secure the sensor to the great toe of the infant and then place a snug-fitting sock on the foot to hold the sensor in place. The nurse should also check the skin under the sensor site frequently for temperature, color, and the presence of a pulse. The nurse should secure the sensor to the index finger of a child and then use a self-adhering bandage to hold the sensor in place; however, this site is not recommended for pulse oximetry of an infant. The nurse should avoid placing the sensor on the heel of the infant's foot because this placement will result in an inaccurate reading.

A nurse is planning an educational program to teach parents about protecting their children from sunburns. Which of the following instructions should the nurse plan to include? a. "allow your child to play outside during the hours between 10:00am and 2:00pm." b. "choose a waterproof sunscreen with a minimum SPF of 15." c. "dress you child in loose weave polyester fabric prior to sun exposure." d. "reapply sunscreen every 4 hours."

B The nurse should instruct parents to avoid allowing their children to play outside during the hours between 1000 and 1400 because the child is at greatest risk for developing a sunburn during this time. The nurse should instruct parents to apply a waterproof sunscreen with a minimum SPF of 15 for children. The parents should apply the sunscreen prior to sun exposure to reduce the risk of sunburn. The nurse should instruct parents to dress their children in tight weave cotton fabric prior to sun exposure to protect the skin from the sun. The nurse should instruct parents to reapply sunscreen every 2 to 3 hr.

A nurse is assessing a 6 month old infant during a well child visit. Which of the following findings should the nurse report to the provider? a. presence of a central incisor tooth b. presence of strabismus c. presence of an open anterior fontanel d. presence of external cerumen

B The nurse should recognize that the presence of a central incisor tooth is an expected finding for a 6-month-old infant and is not necessary to report to the provider. Strabismus, or crossing of the eyes, typically disappears at 3 to 4 months of age. If not corrected early, this can lead to blindness. Therefore, the nurse should report this finding to the provider. The nurse should recognize that the presence of an open anterior fontanel is an expected finding for a 6-month-old infant and is not necessary to report to the provider. The anterior fontanel generally closes around 12 months of age. The nurse should recognize that the presence of cerumen, which is a soft, yellow-brown waxy substance found in the ear, is an expected finding for a 6-month-old infant and is not necessary to report to the provider.

A nurse is caring for a 10 year old child following a head injury. Which of the following findings should the nurse identify as an indication that the child is developing diabetes insipidus? a. urine specific gravity 1.045 b. sodium 155 mEq/L c. blood glucose 45 mg/dL d. urine output 35 mL/hr

B Urine-specific gravity of 1.045 is above the expected reference range of 1.005 to 1.030. A child who has diabetes insipidus is more likely to have diluted urine and a urine-specific gravity below the expected reference range. A child who has a head injury can develop diabetes insipidus as a result of pituitary hypofunction leading to a deficiency of the antidiuretic hormone. Underexcretion of the antidiuretic hormone leads to polyuria and polydipsia, and possibly dehydration. With the excessive loss of free water, sodium levels rise above the expected reference range of 136 to 145 mEq/L. Blood glucose of 45 mg/dL is below the expected reference range of 70 to 110 mg/dL. A child who has diabetes insipidus is expected to have a blood glucose level within the expected reference range. Urinary output of 35 mL/hr is within the expected reference range of 33 to 58 mL/hr for a 10-year-old child. A child who has diabetes insipidus is expected to have polyuria.

A nurse is admitting an infant who has intussesception. Which of the following findings should the nurse expect? (select all that apply) a. steatorrhea b. vomiting c. lethargy d. constipation e. weight gain

B, C The nurse should expect an infant who has intussusception to have bloody stools that are currant jelly-like in appearance. Steatorrhea is bulky, fatty stools, and is a manifestation of cystic fibrosis. The nurse should expect an infant who has intussusception to exhibit vomiting due to the obstruction that occurs when a segment of the bowel telescopes within another segment of the bowel. The nurse should expect an infant who has intussusception to exhibit lethargy due to episodes of severe pain during which the infant cries inconsolably, leading to exhaustion and decreased nutritional intake. The nurse should expect an infant who has intussusception to have mucus-filled and red jelly-like diarrhea due to the leaking of blood and mucus into the intestinal lumen. The nurse should expect an infant who has intussusception to have weight loss due to anorexia and episodes of vomiting and diarrhea.

A nurse in a provider's office is caring for a school age child who has varicella. The parent asks the nurse when their child will no longer be contagious. Which of the following responses should the nurse make? a. "When your child no longer has an increased temperature." b. "Three days after you first noticed the rash appear on your child." c. "When you child's lesions are crusted, usually 6 days after they appear." d. "Two to three weeks, when your child's lesions completely disappear."

C

A nurse is providing discharge teaching to the guardian of a school age child who has undergone a tonsillectomy. Which of the following statements by the guardian indicates an understanding the teaching? a. "my child can resume usual activities since this year just an outpatient surgery." b. "my child will be able to drink the chocolate milkshake I promised to get for them tonight." c. "I will notify the doctor if I notice that my child is swallowing frequently." d. "I will have my child gargle with warm salt water to relieve their sore throat."

C "My child can resume usual activities since this was just an outpatient surgery."Activity should be limited following a tonsillectomy to decrease the risk of hemorrhage. "My child will be able to drink the chocolate milkshake I promised to get for them tonight."Milk products should be avoided because they coat the child's throat, which can initiate a cough response and increase the risk of bleeding. Brown and red foods should be avoided during the immediate postoperative period so that food and fresh or old blood are distinguishable in the child's emesis. "I will notify the doctor if I notice that my child is swallowing frequently."MY ANSWERThe nurse should instruct the parent that frequent swallowing is an indication of bleeding and, if it is observed, to notify the provider immediately. "I will have my child gargle with warm salt water to relieve their sore throat."Gargles are likely to cause irritation and discomfort and can increase the risk of bleeding following a tonsillectomy. The child should receive adequate pain medication following the procedure and can wear an ice collar if tolerated.

A nurse is assessing an adolescent who received a sodium polystyrene sulfonate enema. Which of the following findings indicates effectiveness of the medication? a. reports an absence of nausea and vomiting b. reports experiencing an onset of loose stools within 15 minutes of administration c. serum potassium level 4.1 mEq/L d. blood pressure 86/52 mm Hg

C The absence of nausea and vomiting indicates the effectiveness of the antiemetic medication. Sodium polystyrene sulfonate is an antidote, which exchanges sodium ions in the intestine. Therefore, the absence of nausea and vomiting is not an indicator of the medication's effectiveness. The nurse should monitor the adolescent for diarrhea because it is an adverse effect of sodium polystyrene sulfonate. The nurse should monitor the adolescent's serum potassium level following the administration of sodium polystyrene sulfonate. This medication is used to treat hyperkalemia by exchanging sodium ions for potassium ions in the intestine. Therefore, a potassium level within the expected reference range of 3.4 to 4.7 mEq/L indicates the effectiveness of the medication. Blood pressure of 86/52 mm Hg is below the expected reference range of 90 to 110 mm Hg systolic and 60 to 80 mm Hg diastolic for an adolescent and does not indicate the effectiveness of the medication. The nurse should continue to monitor blood pressure as an indicator of fluid and electrolyte imbalance.

A nurse is providing discharge teaching to the parent of a school age child who has moderate persistent asthma. Which of the following instructions should the nurse include? a. "you should give your child their salmeterol inhaler every 4 hours when they are having an acute episode of wheezing." b. "you should monitor your child's weight weekly while they are receiving inhaled corticosteroids therapy." c. "pulmonary function tests will be performed every 12-24 months to evaluate how your child is responding to therapy." d. "when using the peak expiratory flow meter, record your child's average of three readings."

C "You should give your child their salmeterol inhaler every 4 hours when they are having an acute episode of wheezing."The nurse should inform the parent that long-acting beta2 agonists are to be used in conjunction with a low- or medium-dosage inhaled corticosteroid, and never used alone. Using this medication alone on an as-needed basis during an acute asthma attack is dangerous and can lead to worsening of the child's condition. "You should monitor your child's weight weekly while they are receiving inhaled corticosteroid therapy."The nurse should instruct the parent that the use of inhaled corticosteroids has not been shown to have any negative effects on growth. The provider might monitor the child's growth for systemic absorption; however, it is not necessary for the parent to weigh the child weekly. "Pulmonary function tests will be performed every 12 to 24 months to evaluate how your child is responding to therapy."MY ANSWERThe nurse should inform the parent that their child will need pulmonary function tests every 12 to 24 months to evaluate the presence of lung disease and how the child is responding to the current treatment regimen. As children grow, sometimes their manifestations can improve or decline, and treatment needs to change accordingly. "When using the peak expiratory flow meter, record your child's average of three readings."The nurse should instruct the parent to measure the child's airflow using a peak expiratory flow meter. This should be done twice daily, taking three measurements each time and waiting 30 seconds between each measurement. The parent should record the highest of the three readings, rather than the average.

A nurse in an emergency department is assessing a 3 month old infant who has rotavirus and is experiencing acute vomiting and diarrhea. Which of the following manifestations should the nurse identify as an indication that the infant has moderate to severe dehydration? a. HR 124 b. increased tear production c. sunken anterior fontanel d. capillary refill 2 seconds

C A heart rate of 124/min is within the expected reference range of 106 to 186/min for a 3- to the 5-month-old infant. The nurse should expect the infant who has moderate to severe dehydration to have tachycardia. An infant who has moderate to severe dehydration is more likely to have an absence of tears rather than increased tear production. The nurse should recognize that a sunken anterior fontanel is an indication of moderate to severe dehydration due to the acute loss of fluid. A capillary refill of 2 seconds is within the expected reference range of 2 seconds or less for a 3-month-old infant. An infant who has moderate to severe dehydration is more likely to have a delayed capillary refill of greater than 2 seconds.

A school nurse is caring for a child following a tonic-clonic seizure. Which of the following actions should the nurse take first? a. check the child for a head injury b. observe for oral bleeding c. check the child's respiratory rate d. observe for extremity weakness

C A tonic-clonic seizure is characterized by symmetric contraction and intense jerking movements of the child's body. If the child is standing or sitting in a chair, they will fall to the ground and a head injury can potentially occur. Therefore, it is important to check for a head injury following a tonic-clonic seizure; however, this is not the first action the nurse should take. During a tonic-clonic seizure, a child can lose muscle control and bite down on their tongue. It is important to check for oral bleeding following a tonic-clonic seizure; however, this is not the first action the nurse should take. When using the airway, breathing, and circulation approach to client care, the nurse should determine the priority action is to assess the child's respiratory rate. If the child is not breathing, the nurse should administer rescue breaths. The client might experience extremity weakness due to intense jerking movements following a tonic-clonic seizure; however, this is not the first action the nurse should take.

A nurse is providing discharge teaching to the parent of an 18 month old toddler who has dehydration due to acute diarrhea. Which of the following statements by the parent indicates an understanding of the teaching? a. "I will offer my child small amounts of fruit juice frequently." b. "I will avoid giving my child solid foods until the diarrhea has stopped." c. "I will monitor my child's number of wet diapers." d. "I will give my child polyethylene glycol daily for 7 days."

C Children recovering from dehydration should not be encouraged to drink frequent, small amounts of fruit juice because it is high in carbohydrates, low in electrolytes, and has a high osmolality value. The nurse should teach the parent to encourage solid foods as soon as the toddler is rehydrated to provide adequate nutrient intake. The nurse should teach the parent to closely monitor the child's number of wet diapers. Monitoring the number of wet diapers per day is an effective way for the parent to monitor adequate output and hydration status. Polyethylene glycol is an osmotic agent that will pull fluid into the bowel, increasing the frequency of stools, which will increase the level of dehydration.

A nurse is caring for a newly admitted school age child who has hypopituitarism. Which of the following medications should the nurse expect the provider to prescribe? a. Desmopressin b. Luteinizing hormone-releasing hormone c. Recombinant growth hormone d. Levothyroxine

C Desmopressin is used to treat the hyposecretion of antidiuretic hormones. Luteinizing hormone-releasing hormone is used in the treatment of precocious puberty to slow prepubertal growth in children and in the treatment of advanced prostate cancer in adult clients. Recombinant growth hormone injections are used to treat hypopituitarism, which inhibits cell growth and results in growth failure. The nurse should expect the provider to prescribe this treatment. Levothyroxine is used to treat various hypothyroid conditions.

A charge nurse is preparing to make a room assignment for a newly admitted school age child. Which of the following considerations is the nurse's priority? a. length of stay b. treatment schedule c. disease process d. self-care ability

C It is important for the nurse to consider the child's anticipated length of stay because some client rooms might be larger, and thus more comfortable for families during long hospitalizations. However, this is not the nurse's priority consideration. It is important for the nurse to consider the child's treatment schedule when making room assignments because children requiring frequent monitoring and treatment should be assigned a room close to the nurses' station, if possible. However, this is not the nurse's priority consideration. The transmission of infectious diseases is the greatest risk to this child and other children on the unit. Therefore, the child's disease process is the nurse's priority consideration. It is important for the nurse to consider the child's self-care ability when making room assignments because children who require more assistance from nurses or assistive personnel should be assigned a room close to the nurses' station, if possible. However, this is not the nurse's priority consideration.

A nurse is assessing an 8 year old child who has early indication of shock. After establishing an airway and stabilizing the child's respirations, which of the following actions should the nurse take next? a. insert an indwelling urinary catheter b. measure weight and height c. initiate IV access d. maintain ECG monitoring

C The nurse should insert an indwelling urinary catheter for a child who has early indications of shock. Strict intake and output monitoring are needed because urinary output decreases during shock due to reduced blood flow to the kidneys as the body attempts to conserve body fluids. However, there is another action that the nurse should take first. The nurse should measure the weight and height of a child who has early indications of a shock to calculate weight-based medication dosages. However, there is another action that the nurse should take first. After establishing an airway and stabilizing the child's respirations, the next action the nurse should take when using the airway, breathing, and circulation approach to client care is to establish IV access to maintain the child's circulatory volume. The nurse should maintain ECG monitoring for a child who has early indications of a shock to continually assess for changes in cardiac status. However, there is another action that the nurse should take first.

A nurse is caring for a 1 month old infant who is breastfeeding and requires a heel stick. Which of the following actions should the nurse take to minimize that infant's pain? a. Use a manual lancet to obtain the heel blood sample b. apply an ice pack to the infant's heel prior to obtaining the sample c. allow the mother to breastfeed while the sample is being obtained d. apply a topical lidocaine cream prior to obtaining the sample

C The use of a manual lancet should be avoided because it can cause more discomfort. The evidence-based practice recommends using an automatic lancet to obtain heel samples because it is safer and less traumatic. The nurse should apply a heating pad to the infant's heel prior to obtaining the sample. This will increase blood flow to the site, which will make the sample easier to obtain. The nurse should allow the mother to breastfeed the infant prior to or during the procedure. Evidence-based practice indicates breastfeeding or non-nutritive sucking with a pacifier can provide nonpharmacological pain management in infants. The use of topical lidocaine is not an effective pain management technique for a heel stick.

A nurse is reviewing the dietary choices of an adolescent who has iron deficiency anemia. The nurse should identify that which of the following menu items has the highest amount of nonheme iron? a. 1/2 cup whole milk b. 1 cup orange juice c. 1/2 cup raisins d. 1 cup raw carrots

C Whole milk does not contain the highest amount of nonheme iron. However, it does contain high amounts of calcium. Orange juice does not contain the highest amount of nonheme iron. However, it does contain ascorbic acid, which increases the amount of nonheme iron absorbed by the body. The nurse should encourage the adolescent to eat raisins because they contain the highest amount of nonheme iron. Raw carrots do not contain the highest amount of nonheme iron.

A nurse is planning care for a newly admitted school age child who has generalized seizure disorder. Which of the following interventions should the nurse plan to include? a. ensure that a padded tongue blade is at the child's bedside b. allow the child to play video games on a tablet computer c. allow the child to take a tub bath independently d. ensure the oxygen source is functioning in the child's room

D Bright or flashing lights from video games can trigger seizure activity. The nurse should decrease environmental stimuli and offer other play activities, such as reading a book or playing with a stuffed animal. The nurse should allow the child to take a tub bath with supervision, but not independently. There should be someone available to assist the child if they experience a seizure. The nurse should recognize that maintaining the child's airway is important during a seizure. The nurse should ensure that the oxygen source is functioning because the child might require supplemental oxygen following a seizure.

A nurse is creating a plan of care for a newly admitted adolescent who has bacterial meningitis. How long should the nurse plan to maintain the adolescent in droplet precautions? a. until the adolescent is afebrile b. for 7 days following admission to the facility c. until the adolescent has a negative blood culture d. for 24 hrs following initiation of antimicrobial therapy

D A temperature within the expected reference range for an adolescent can be achieved with acetaminophen. Therefore, this is not a determinant factor for removing a client from droplet precautions. The adolescent is not contagious for 7 days. Therefore, it is not necessary for the nurse to maintain droplet precautions for that length of time. Blood cultures should be drawn before the first dose of antibiotics. It usually takes 48 to 72 hr for the organism to grow enough for identification. The test should be repeated after the entire antibiotic regimen is completed to determine if the infection is still present. Therefore, blood cultures are not a determinant factor for removing a client from droplet precautions. The nurse should plan to maintain the adolescent on droplet precautions for at least 24 hr following the initiation of antimicrobial therapy. This practice will ensure that the adolescent is no longer contagious, which protects family members and the person caring for the client. Prophylactic antibiotics might be prescribed to individuals who were in close contact with the adolescent.

A community health nurse is assessing an 18 month old toddler in a community day care. Which of the following findings should a nurse identify as a potential indication of physical neglect? a. resists having an axillary temperature taken b. exhibits withdrawal behaviors when their parent leaves c. has multiple bruises on their knees d. poor personal hygiene

D A toddler has begun to develop a sense of body image and boundaries and can be resistant to intrusive assessments such as assessing the mouth or ears, or taking an axillary temperature. Therefore, this finding is not an indication of physical neglect. Separation anxiety is an expected finding for a toddler. Toddlers can become fearful and exhibit regressive behaviors when left alone with strangers and separated from their parents. Therefore, this finding is not an indication of physical neglect. An 18-month-old toddler has typically accomplished the gross motor skills of standing and walking, and has likely started trying to run, which can result in them falling and bruising their knees. Therefore, this finding is not an indication of physical neglect. A toddler who has poor personal hygiene can be a potential indication of physical neglect. Because toddlers are still dependent on their parents or guardians for help with hygiene needs, poor personal hygiene can indicate a lack of supervision.

A nurse is providing anticipatory guidance to the parent of a toddler. Which of the following expected behavior characteristics of toddlers should the nurse include? a. controls impulsive feelings b. understands right from wrong c. easily separates from parents for long periods of time d. expresses likes and dislikes

D Controlling impulsive feelings is expected behavior of school-age children. Toddler is more likely to have difficulty controlling strong and impulsive feelings as they try to assert their independence and gain control of situations. Understanding right from wrong and modifying their behavior in response to others' expectations is the expected behavior of preschoolers. Toddlers tend to have a great deal of curiosity and ask many questions but are not able to fully understand what behaviors are right or wrong. A toddler might be able to separate from their parents for a short period of time, but toddlers are more likely to experience acute separation anxiety when separated from their parents for an extended period of time. The toddler might offer resistance if they are left with a new babysitter or at a new daycare center. Nurses should include that expressing likes and dislikes is an expected behavior of toddlers. This is the time in life when a toddler is developing autonomy and self-concept. They will try to assert themselves and frequently refuse to comply. The parent should allow the child to have some control, but also set limits for them so they learn from their behavior and learn to control their actions.

A school nurse is providing an in service for faculty about improving education for students who have ADHD. Which of the following statements by a faculty member indicates an understanding of the teaching? a. "I will plan to increase the amount of homework I assign to students who have ADHD." b. "I will give students who have ADHD the same amount of time as other students to complete tests." c. "I will allow students who have ADHD one rest break throughout the day." d. "I will teach challenging academic subjects to students who have ADHD in the morning."

D Faculty should plan to teach challenging academic subjects in the morning when students who have ADHD are most able to focus and their medication is most likely to be effective.

A nurse is providing discharge teaching to the parents of a 6 month old infant who is postoperative following hypospadias repair with a stent placement. Which of the following instructions should the nurse include in the teaching? a. "you may bathe your infant in an infant bathtub when you go home." b. "apply hydrocortisone cream to your infant's penis daily." c. "you should clamp your infant's stent twice daily." d. "allow the stent to drain directly into your infant's diaper."

D Submerging the stent in water can cause infection at the operative site. The parents should avoid placing the infant in an infant bathtub until after the provider removes the stent. Following surgical repair of hypospadias, the infant is at increased risk for infection at the operative site. The nurse should instruct the parents to administer a prophylactic antibiotic as prescribed to help prevent infection. The stent in place following hypospadias repair allows urine to drain from the body. The nurse should instruct the parents to avoid blocking the stent to prevent urinary stasis and potential injury to the infant. The nurse should instruct the parents to ensure that the stent drains directly into the infant's diaper to prevent kinking or twisting which can interfere with urine flow.

A nurse is planning care for a school age child who has a tunneled central venous access device. Which of the following interventions should the nurse include in the plan? a. use sterile scissors to remove the dressing from the site b. irrigate each lumen weekly with 10 ml of 0.9% sodium chloride solution when not in use c. access the site suing a noncoring angle needle d. use a semipermeable transparent depressing to cover the site

D The nurse should avoid the use of scissors when performing dressing changes because this can result in the accidental cutting of the catheter. The nurse should flush each lumen of the catheter with a heparin solution daily when not in use. The nurse should use a non-coring angled or straight needle when accessing an implanted port. The nurse should cover the site with a semipermeable transparent dressing to reduce the risk of infection.

A nurse is creating a plan of care for a child who has varicella. which of the following interventions should the nurse include? a. maintain the child's room temperature at 80 degrees F b. prepare the child for a lumbar puncture c. administer aspirin to the child for a temperature greater than 38.3 degrees C (101 degrees F) d. initiate airborne precautions for the child

D The nurse should ensure that a child who has varicella remains cool. Cooler temperatures decrease pruritis. Maintaining the child's room at a warm temperature will increase the child's discomfort. The nurse should prepare a child who has bacterial meningitis for a lumbar puncture. Guardians should be instructed to avoid the administration of aspirin when the child has a viral varicella infection due to the possibility of causing the development of Reye syndrome, which can be fatal. The nurse should initiate airborne precautions for a child who has varicella because it is spread through droplets in the air. The incubation period for varicella is 2 to 3 weeks, and the child is contagious even before lesions appear.

A nurse is caring for a preschooler who has congestive heart failure. The nurse observes wide QRS complexes and peaked T waves on the cardiac monitor. Which of the following prescriptions should the nurse clarify with the provider? a. furosemide b. captopril c. regular insulin d. potassium chloride

D The nurse should identify that a child who has congestive heart failure can develop electrolyte imbalances, such as hyperkalemia or hypokalemia. The nurse should identify that the child is exhibiting manifestations of hyperkalemia and contact the provider about the administration of potassium chloride, which can increase the severity of hyperkalemia.

A nurse is discussing organ donation with the parents of a school age child who has sustained brain death due to a bicycle crash. Which of the following actions should the nurse take first? a. inform the parents that written consent is required prior to organ donation b. provide written information to the parents about organ donation c. ask the provider to explain misconceptions of organ donation to the parents. d. explore the parents feelings and wishes regarding organ donation

D The nurse should inform the parents that written consent is required prior to organ donation to document that the parents have consented to organ donation and that the provider has addressed any questions or concerns the parents might have. However, there is another action the nurse should take first. The nurse should provide written information to the parents to enhance their understanding of organ donation. However, there is another action the nurse should take first. The nurse should ask the provider to explain misconceptions of organ donation to the parents because it is important that they have accurate information before making a final decision. However, there is another action the nurse should take first. The first action the nurse should take when using the nursing process is assessment. The nurse should first explore the parents' feelings and wishes regarding organ donation to assist in determining if organ donation is the right choice for the family.

A nurse is providing discharge teaching to he parents of a 3 month old infant following a cheiloplasty. Which of the following instructions should the nurse include? a. "clean your baby's sutures daily with a mixture of chlorhexidine and water." b. "expect your baby to swallow more than usual over the next few days." c. "inspect your baby's tongue for white patches using a tongue depressor every 8 hours." d. "apply a thin layer of antibiotic ointment on your baby's suture line daily for the next 3 days."

D The nurse should instruct the parents to clean the infant's sutures with sterile water or diluted hydrogen peroxide. The nurse should instruct the parents to notify the provider of excessive swallowing because this can indicate bleeding and the infant's swallowing of blood. The nurse should instruct the parents to avoid placing objects, such as tongue depressors, in the infant's mouth to prevent injury to the suture line. The nurse should instruct the parents to apply a thin layer of antibiotic ointment on the infant's suture line daily for 3 days and then continue to apply petroleum jelly to the area for several weeks to promote healing.

A nurse is planning care to address nutritional needs for a preschooler who has cystic fibrosis. Which of the following interventions should the nurse include in the plan? a. administer pancreatic enzymes 2 hours after meals b. discontinue the use of pancreatic enzymes if steatorrhea develops c. limit fluid intake to 750 mL per day d. increase fat content in the child's diet to 40% of total calories.

D The nurse should plan to administer pancreatic enzymes within 30 min of meals and snacks to replace the enzymes lost with cystic fibrosis. A child who has cystic fibrosis and develops steatorrhea, or fatty stools, might need to have their dosage of pancreatic enzyme increased by their provider until the steatorrhea resolves. The nurse should encourage fluid intake, rather than restrict it, to prevent dehydration caused by the loss of sodium and chloride through perspiration. A child who has cystic fibrosis is unable to properly digest fats due to fibrosis of the pancreas and limited secretion of pancreatic enzymes. The nurse should increase the child's fat intake to 35% to 40% of the total caloric intake.

A nurse is performing hearing screenings for children at a community health fair. Which of the following children should the nurse refer to a provider for a more extensive hearing evaluation? a. an 18 month old toddler who has unintelligible speech b. a 3 month old infant who has exaggerated startle response c. a 4 year old preschooler who prefers playing with others rather than alone d. an 8 month old infant who is not yet making babbling sounds

D The nurse should refer a toddler who does not possess intelligible speech by the age of 24 months to a provider for a more extensive evaluation of hearing. The nurse should refer infants who are under the age of 4 months and lack a startle response to a provider for a more extensive evaluation of hearing. The nurse should refer a preschooler who prefers playing alone and avoids interaction with others to a provider for a more extensive evaluation of hearing. The nurse should refer an infant who is not making babbling sounds by the age of 7 months to a provider for a more extensive evaluation of hearing.

Graphic Record Temperature 37.5° C (99.5° F) Heart rate 70/min Respiratory rate 30/min Birth weight 3.2 kg (7 lb) Current weight 5.9 (13 lb) Nurses' Notes 3 episodes of vomiting 6 wet diapers in 24 hr Consumed 3 oz concentrated formula every 3 hr Medication Administration Record Digoxin 0.5 mcg PO Q12H Furosemide 20 mg PO Q12H

Episodes of vomiting When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority finding is three episodes of vomiting. This can indicate digoxin toxicity, which requires immediate intervention. Therefore, this is the nurse's priority finding.

A nurse is caring for a preschooler who was recently admitted to a pediatric unit. Nurses' Notes The preschooler's guardians report that their child had a gastrointestinal illness with some vomiting and diarrhea about 1 week ago. Their child started to feel better. However, within the last 2 days, they noticed several small bruises that appeared on their child's arms and legs. Additionally, the guardians report the child is lethargic. Vital Signs 0900: Temperature 37.2° C (99.0° F)Heart rate 110/min Respiratory rate 22/minBlood pressure 108/70 mm HgOxygen saturation 98% on room air Pain rating per FLACC scale 01000: Temperature 38.2° C (100.8° F)Heart rate 108/min Respiratory rate 22/min Blood pressure 114/74 mm HgOxygen saturation 98% on room air Pain rating per FLACC scale 0. Diagnostic Results Hemoglobin 8.8 g/dL (9.5 to 14 g/dL)Hematocrit 28% (30% to 40%)WBC count 8,000/mm3 (5,000 to 10,000/mm3)Platelets 1

For each EMR finding, click to specify if the finding is consistent with nephrotic syndrome, acute poststreptococcal glomerulonephritis, or hemolytic uremic syndrome. Each finding may support more than one disease process. Temperature is consistent with acute poststreptococcal glomerulonephritis and hemolytic uremic syndrome. According to the EMR, the child's temperature is outside the expected reference range and is increasing. A child who has acute post-streptococcal glomerulonephritis may present with a low-grade fever. The child who has hemolytic uremic syndrome may experience a fever that is high enough to cause hallucinations and lethargy. The BUN level is consistent with acute post-streptococcal glomerulonephritis and hemolytic uremic syndrome. According to the EMR, the child's BUN level is elevated, which indicates an impairment of kidney function. With acute post-streptococcal glomerulonephritis, a streptococcal infection invades the inner membranes of the kidney, which affects filtration and blood flow. With hemolytic uremic syndrome, intravascular coagulation occurs in the endothelium of the glomeruli of the kidneys, which impairs filtration and blood flow. Platelet count is consistent with the hemolytic uremic syndrome. According to the EMR, the child's platelet count is low, which indicates thrombocytopenia. With hemolytic uremic syndrome, intravascular coagulation occurs in the endothelium of the glomeruli of the kidneys, which impairs filtration and blood flow due to the aggregation of platelets. Blood pressure is consistent with nephrotic syndrome, acute post-streptococcal glomerulonephritis, and hemolytic uremic syndrome. According to the EMR, the child's blood pressure is elevated, which indicates a narrowing of the blood vessels, possibly due to kidney impairment from these conditions. Cholester

A nurse on a pediatric unit is caring for a toddler. Medical History Hemophilia A Nurses' Notes 1100: Guardian reports that the toddler fell at home while playing with toys. Since the fall, the toddler has been very irritable, crying uncontrollably, and grabbing at their left knee. The toddler can walk but insists on being picked up. Physical Examination 1115: Toddler is alert during the exam. Extremities are warm and dry to touch. Decreased movement of the left leg observed. Tenderness noted with palpation of the left knee joint. Pain level assessed as 6 on a scale of 0 to 10 using the FLACC scale. 1145: Toddler is fussy and crying. Pain assessed as 8 on scale of 0 to 10 using the FLACC scale. Left knee observed to be ecchymotic and edematous. Vital Signs 1115: Temperature 36.9° C (98.4° F)Heart rate 110/minRespiratory rate 28/minOxygen saturation 98% on room air.

For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the toddler. Administer factor VIII is anticipated. The child is experiencing an acute episode of hemophilia due to a recent fall. During this acute episode, there is potential for internal bleeding into the joint spaces. Therefore, administering factor VIII is anticipated to control bleeding. Apply ice packs to the affected joints is anticipated. The child is experiencing an acute episode of hemarthrosis due to a recent fall, as evidenced by the bruising and swelling of the knee joint. Therefore, applying ice packs to the affected joints is anticipated to manage discomfort and decrease bleeding into the joint. Administer morphine PRN pain is anticipated. The child is experiencing severe pain. Opioids can be administered in the inpatient setting to relieve pain. Otherwise, acetaminophen can be given at home for pain. Aspirin and NSAIDs should be avoided because they inhibit platelet function and might increase bleeding. Perform passive range-of-motion (ROM) exercises during the first 12 hr following injury is contraindicated. The child is experiencing an acute episode of hemarthrosis. Passive ROM exercises can increase bleeding into the joint for the first 48 hr following injury. The toddler should be encouraged to exercise the joint as tolerated. Elevate the affected joints is anticipated. The child is experiencing an acute episode of hemarthrosis due to a recent fall, as evidenced by the bruising and swelling of the knee joint. Elevation of the joint, along with the application of ice, is anticipated to help decrease bleeding and swelling in the joint.

A nurse is caring for a school-age child following an appendectomy. Vital Signs Day of admission: Temperature 37.1° C (98.8° F)Heart rate 100/min Respiratory rate 20/min Blood pressure 94/60 mm Hg Pulse oximetry 97%24 hr following the procedure: Temperature 38.6° C (101.5° F)Heart rate 110/min Respiratory rate 24/min Blood pressure 100/60 mm Hg Pulse oximetry 95%. Nurses' Notes Day of admission: Child is drowsy but easily aroused and responsive to verbal stimuli. Child rates pain as 4 on a scale of 0 to 10. Lungs clear to auscultation. Abdomen is soft, flat, and non-distended. Bowel sounds hypoactive in all four quadrants. Extremities are warm and dry to touch. Gauze pads with clear transparent dressings noted to the umbilicus, left lower quadrant, and suprapubic area. 24 hr following the procedure: Child is alert and responsive to verbal stimuli. Appears irritable and restless. Child rates pain as 8 on a scale

Select the 3 findings from the child's medical record that the nurse should identify as indications of a potential complication. WBC count is correct. The child's WBC count has increased significantly following the procedure. The nurse should identify that this is a potential indication of a postoperative infection. Abdomen assessment is correct. The child's abdomen is rigid and distended and they are reporting increased pain. The nurse should identify that this is a potential indication of a postoperative infection. Temperature is correct. One day following surgery, the child's temperature has increased and is above the expected reference range. The nurse should identify that this is a potential indication of a postoperative infection.

A nurse on a pediatric unit is caring for a school-age child. 0830: The child is alert and responsive to stimuli. Skin is warm and dry. Capillary refill less than 3 seconds. Respirations are regular and shallow. Mild intercostal retractions noted. Expiratory wheezes auscultated in the anterior and posterior lung bases. The abdomen is soft, flat, and non-distended. 1100: The child appears restless. Moderate intercostal retractions noted. Scattered rhonchi anterior bases with wheezing were noted on inhalation and exhalation. Point of maximum intensity (PMI) in the left mid-clavicular line 4th intercostal space. Heart rate is regular without murmurs, gallops, or rubs. Radial and pedal pulse 2+ bilaterally. 0830: Temperature 37.1° C (98.8° F)Heart rate 100/min Respiratory rate 22/minBlood pressure 90/60 mm HgPulse oximetry 97% on 2 L of oxygen via nasal cannula 1100: Temperature 37.1° C (98.8° F)Heart rate 110/min R

The child's arterial blood gases (ABGs) indicate respiratory alkalosis, which is associated with complications of asthma, such as hyperventilation and hypoxia. Therefore, the nurse should report these findings to the provider. The child's WBC count is above the expected reference range, which could be an indication of infection or inflammation. Therefore, the nurse should report this finding to the provider. The child's oxygen saturation level has decreased below the expected reference range despite the use of supplemental oxygen. Therefore, the nurse should report this finding to the provider. The respiratory assessment is correct. The child's respiratory assessment indicates increased respiratory distress, as evidenced by the presence of tachypnea, retractions, and increased wheezing. Therefore, the nurse should report these findings to the provider.

A nurse is caring for an 8-month-old infant. Nurses' Notes Day of admission 0515: Infant is admitted for moderate acute laryngotracheobronchitis (LTB) and decreased fluid intake. The infant's parent reports it has been more than 12 hr since the infant last voided. The infant is restless, irritable, has a hoarse cry, and is not easily consoled by the parent. Audible inspiratory stridor is evident with a barky sounding occasional non-productive cough. Respiratory rate is 78/min with moderate suprasternal and intercostal retractions and nasal flaring. SpO2 is 89%. Color of mucous membranes is consistent with the client's genetic background. Capillary refill is 2 seconds, mucus membranes are slightly dry, and skin turgor is good. IV of dextrose 5% in 0.45% sodium chloride is infusing at 30 mL/hr. 100% cool mist oxygen is being given via blow-by tubing that the parent is holding.0600:SpO2 is 92%. Breath sounds are dimini

Upon evaluation of the infant's status at 0630, the nurse should identify which of the following as signs of improvement? Click to highlight the statements in the Nurses' Notes that indicate the infant is improving.

A nurse in the ED is auscultating the lungs of an adolescent who is experiencing dyspnea. The nurse should identify the sound as which of the following?

WheezesMY ANSWERThe nurse should identify the sound during auscultation as wheezes, which are high-pitched, musical or whistling-like sounds heard primarily on expiration as air passes through and vibrates narrowed airways. CracklesThe nurse should identify crackles as high-pitched, short, and noncontinuous sounds usually heard at the end of inspiration. Crackles occur when air expands deflated alveoli or when the passage of air through small airways is disrupted. Pleural friction rubThe nurse should identify a pleural friction rub as a loud, rough, grating sound that can be heard during inspiration or expiration. A pleural friction rub occurs when the pleurae are inflamed and the surfaces rub together. RhonchiThe nurse should identify rhonchi as low-pitched, continuous sounds that have a snore-like quality and are usually louder during expiration. Rhonchi occur when the larger airways are obstructed.

A nurse in a provider's office is caring for a preschooler. 0915:Guardians report that lately the child has had severe itching and is breaking out with sores on their eyebrows, wrists, and ankles. The "sores started to bleed." Guardians report no relief with the application of the topical hydrocortisone cream. 0930:Child is alert. Multiple small erythematous papules with some scaling were noted on the child's eyebrows, forearms, and lower legs bilaterally. 1015:Provider in to evaluate the child. Discharge to home after medication administration of new prescriptions and discharge teaching for atopic dermatitis. Family history of atopic dermatitis. Medication Administration Record 1000: Loratadine (oral solution) 5 mg PO daily. Administer the first dose now prior to discharge.​ Tacrolimus 0.03% ointment. Apply a thin layer to affected areas twice daily; rub in gently and completely. Return to a primary care provide

Which of the following statements by a guardian indicates that the discharge teaching was effective? Select all that apply. "We should apply a skin emollient immediately after bathing our child" is correct. An emollient is an oil that moisturizes the skin and should be applied immediately after bathing while the skin is damp to prevent drying. Therefore, this statement by the guardian indicates the teaching has been effective. "We should keep our child's fingernails trimmed short" is correct. The child's fingernails and toenails should be kept short, trimmed, and filed to prevent scratching with sharp edges. Therefore, this statement by the guardian indicates the teaching has been effective. "We should use a mild detergent for our laundry" is correct. The use of mild detergents for laundry helps prevent allergens and itching. Therefore, this statement by the guardian indicates the teaching has been effective.