ATI RN Nursing Care of Children 2019 A

A nurse is teaching the patient of an infant about ways to prevent sudden infant death syndrome (SIDS). Which of the following instructions should the nurse include? - "Place the infant in a prone position to sleep." - "Allow the infant to sleep on a large pillow." - "Use a soft mattress in the infant's crib." - "Give the infant a pacifier at bedtime."

- "Give the infant a pacifier at bedtime." RATIONALE: The nurse should inform the parent that protective factors against SIDS include breastfeeding and the use of a pacifier when the infant is sleeping.

A nurse in an emergency department is caring for a school-age child who is experiencing an anaphylactic reaction. Which of the following is the priority action by the nurse? - Elevate the head of the child's bed - Insert a large bore IV catheter for the child - Determine the allergen that caused the child's reaction - Administer epinephrine IM to the child

- Administer epinephrine IM to the child RATIONALE: When using the urgent vs. nonurgent approach to client care, the nurse should determine that the priority action is administering epinephrine IM to the child. During an anaphylactic reaction, histamine release causes bronchoconstriction and vasodilation. This is an emergency because ultimately this causes decreased blood return to the heart.

A nurse is preparing to administer an immunization to a 4-year-old child. Which of the following actions should the nurse plan to take? - Place the child in a prone position for the immunization - Request that the child's caregiver leave the room during the immunization - Administer the immunization using a 24-gauge needle - Inject the immunization slowly after aspirating for 3 seconds

- Administer the immunization using a 24-gauge needle RATIONALE: The nurse should administer an immunization for a 4-year-old child using a 22- to 25-gauge needle to minimize the amount of pain the child experiences.

A nurse is receiving the laboratory report of a 7-year-old child who is receiving chemotherapy. Which of the following laboratory values should the nurse report to the provider? - Hgb 8.5 g/dL - WBC count 9,500/mm3 - Prealbumin 18 mg/dL - Platelets 300,000/mm3

- Hgb 8.5 g/dL RATIONALE: A child receiving chemotherapy is at risk for anemia due to the chemotherapy effects on the blood-forming cells of the bone marrow. The development of anemia is diagnosed through laboratory testing of hemoglobin & hematocrit levels. The nurse should recognize that a hemoglobin level of 8.5 g/dL is below the expected reference range of 10 to 15.5 g/dL for a 7-year-old child and should be reported to the provider.

A nurse is providing discharge teaching to the parent of a child who is 1 week postoperative following a cleft palate repair. For which of the following members of the interprofessional team should the nurse initiate a referral? - Occupational therapist - Speech therapist - Respiratory therapist - Physical therapist

- Speech therapist RATIONALE: The nurse should initiate a referral for a speech therapist for a child who is postoperative following a cleft palate repair. A child who has a cleft palate will require speech therapy immediately following the repair to support speech development and future articulation.

A nurse is reviewing the laboratory report of a 7-year-old child who is receiving chemotherapy. Which of the following laboratory values should the nurse report to the provider? - Hgb 8.5 g/dL - WBC count 9,500/mm3 - Prealbumin 18 mg/dL - Platelets 300,000/mm3

- Hgb 8.5 g/dL RATIONALE: A child receiving chemotherapy is at risk for anemia due to the chemotherapy effects on the blood-forming cells of bone marrow. The development of anemia is diagnosed through laboratory testing of hemoglobin & hematocrit levels. The nurse should recognize that a hemoglobin level of 8.5 g/dL is below the expected reference range of 10-15.5 g/dL for a 7-year-old child & should be reported to the provider.

A nurse is creating a plan of care for an infant who has an epidural hematoma from a head injury. Which of the following interventions should the nurse include in the plan? - Position the infant side-lying with their head at a 0-degree to 5-degree angle - Perform a neurological assessment every 4 hr - Suction the infant's nares to remove secretions - Implement seizure precautions for the infant

- Implement seizure precautions for the infant RATIONALE: An infant who has an epidural hematoma is at great risk for seizure activity. Therefore, the nurse should implement seizure precautions.

A nurse is planning care for a school-age child who is in the oliguric phase of acute kidney injury (AKI) and has a sodium level of 129 mEq/L. Which of the following interventions should the nurse include in the plan? - Administer ibuprofen to the child for a temperature greater than 38 C (100.4 F) - Assess the child's blood pressure every 8 hr - Weigh the child weekly at various times of the day - Initiate seizure precautions for the child

- Initiate seizure precautions for the child RATIONALE: A sodium level of 129 mEq/L indicates hyponatremia and places the child at increased risk for neurological deficits and seizure activity. The nurse should complete a neurologic assessment and implement seizure precautions to maintain the child's safety.

A nurse is caring for a toddler who is experiencing acute diarrhea and has moderate dehydration. Which of the following nutritional items should the nurse offer to the toddler? - Apple juice - Peanut butter - Chicken broth - Oral rehydration solution

- Oral rehydration solution RATIONALE: A toddler who has acute diarrhea should consume an oral rehydration solution to replace electrolytes and water by promoting the reabsorption of water and sodium. This promotes recovery from dehydration.

A nurse is preparing to collect a sample from a toddler for a sickle-turbidity test. Which of the following actions should the nurse plan to take? - Obtain a sputum specimen - Perform an Allen test - Perform a finger stick - Obtain a stool specimen

- Perform a finger stick RATIONALE: The nurse should perform a finger stick on a toddler as a component of the sickle-turbidity test. If the test is positive, hemoglobin electrophoresis is required to distinguish between children who have the genetic trait & children who have the disease.

A nurse is assessing a school-age child who has meningitis. Which of the following findings is the priority for the nurse to report to the provider? - Reports a headache as 6 on a scale of 0 to 10 pain scale - Petechiae on the lower extremities - Nuchal rigidity - Positive Kernig's sign

- Petechiae on the lower extremities RATIONALE: The presence of a petechial or purpuric rash on a child who is ill can indicate the presence of meningococcemia. This type of rash indicates the greatest risk of serious rapid complications from sepsis and should be reported immediately to the provider.

A charge nurse in an emergency department is preparing an in-service for a group of newly licensed nurses about the manifestations of child maltreatment. Which of the following manifestations should the charge nurse include as a potential indication of physical abuse? - Recurrent urinary tract infections - Symmetric burns on the lower extremities - Failure to thrive - Lack of subcutaneous fat

- Symmetric burns on the lower extremities RATIONALE: The nurse should include that symmetric burns to the lower extremities can indicate physical abuse. The patterns are usually characteristic of the method or object used, such as cigar or cigarette burns, or burns in the shape of an iron.

A nurse is interviewing the parent of an 18-month-old toddler during a well-child visit. The nurse should identify that which of the following findings indicates a need to assess the toddler for hearing loss? - The toddler has a vocabulary of 25 words - The toddler developed a mild rash following a recent varicella immunization - The toddler's Moro reflex is absent - The toddler received tobramycin during a hospitalization 2 weeks ago.

- The toddler received tobramycin during a hospitalization 2 weeks ago. RATIONALE: The nurse should identify tobramycin as an aminoglycoside, which is an ototoxic medication that can cause mild to moderate hearing loss, and should assess the toddler for a hearing impairment.

A nurse in a provider's office is preparing to administer immunizations to a toddler during a well-child visit. Which of the following actions should the nurse take? - Withhold the measles, mumps, and rubella (MMR) vaccine. - Withhold the diphtheria, tetanus, and pertussis (DTaP) vaccine. - Withhold the influenza vaccine. - Withhold the tuberculin skin test (TST).

- Withhold the measles, mumps, and rubella (MMR) vaccine. RATIONALE: The nurse should recognize that an allergy to neomycin with an anaphylactic reaction is a contraindication for receiving the MMR vaccine. Clients who have a severe allergy to eggs or gelatin should not receive this vaccine.

A nurse is providing teaching to the parent of an infant who has diaper dermatitis. The nurse should instruct the parent to apply which of the following to the affected area? - Zinc oxide - Antibiotic ointment - Talcum powder - Antiseptic solution

- Zinc oxide RATIONALE: Diaper dermatitis is a common inflammatory skin disorder caused by contact with an irritant such as urine, feces, soap, or friction, & takes the form of scaling, blisters, or papules with erythema. Providing a protective barrier, such as zinc oxide, against the irritants allows the skin to heal.

A nurse is providing teaching to the parent of a school-age child who has a new prescription for oral nystatin for the treatment of oral candidiasis. Which of the following instructions should the nurse include? - "Shake the medication prior to administration." - "Provide the medication through a straw." - "Rinse the child's mouth with water immediately after giving the medication." - "Mix the medication with applesauce if the child dislikes the taste."

- "Shake the medication prior to administration." RATIONALE: The nurse should instruct the parent to shake the medication prior to administration to disperse the medication evenly within the suspension.

A nurse in an emergency department is caring for a toddler who has partial-thickness burns on their right arm. Which of the following actions should the nurse take? - Insert an NG tube - Initiate prophylactic antibiotic therapy - Cleanse the affected area with mild soap and water - Apply a topical corticosteroid to the affected area

- Cleanse the affected area with mild soap and water RATIONALE: The nurse should wash the affected area with mild soap and water to remove any loose tissue that could cause infection.

A nurse is providing teaching about play activities for social development to the parents of a preschooler. Which of the following play activities should the nurse recommend for the child? - Playing pat-a-cake - Using a push-pull toy - Creating a scrapbook - Playing dress-up

- Playing dress-up RATIONALE: The nurse should instruct the parents that at the preschool age, play should focus on social, mental, & physical development. Therefore, playing dress-up is a recommended play activity for this child.

A nurse is creating a plan of care for a school-age child who has heart disease and has developed heart failure. Which of the following interventions should the nurse include in the plan? - Provide small, frequent meals for the child - Schedule time in the play room for the child - Weigh the child weekly - Maintain the child in a supine position

- Provide small, frequent meals for the child RATIONALE: The metabolic rate of a child who has heart failure is high because of poor cardiac function. Therefore, the nurse should provide small, frequent meals for the child because it helps to conserve energy.

A nurse is planning care for a toddler who has a serum lead level of 4 mcg/dL. Which of the following actions should the nurse plan to take? - Instruct the parents to decrease the calcium in their toddler's diet - Prepare the toddler for chelation therapy. - Refer the family to Child Protective Services. - Schedule the toddler for a yearly rescreening.

- Schedule the toddler for a yearly rescreening. RATIONALE: The nurse should schedule the toddler for a lead level rescreening in 1 year & educate the family on ways to prevent exposure.

A nurse is caring for a toddler who has a serum lead level of 4 mcg/dL. Which of the following actions should the nurse plan to take? - Instruct the parents to decrease the calcium in their toddler's diet - Prepare the toddler for chelation therapy - Refer the family to Child Protective Services - Schedule the toddler for yearly screening

- Schedule the toddler for yearly screening RATIONALE: The nurse should schedule the toddler for a lead level rescreening in 1 year and educate the family on ways to prevent exposure.

A nurse is admitting a school-age child who has pertussis. Which of the following actions should the nurse take? - Place the child in a room with positive-pressure airflow - Place the child in a room with negative-pressure airflow - Initiate contact precautions for the child - Initiate droplet precautions for the child

- Initiate droplet precautions for the child RATIONALE: The nurse should initiate droplet precautions for a child who has pertussis, also known as whooping cough. Pertussis is transmitted through contact with infected large-droplet nuclei that are suspended in the air when the child coughs, sneezes, or talks.

A nurse is assessing a toddler who has gastroenteritis & is exhibiting manifestations of dehydration. Which of the following findings is the nurse's priority? - Skin breakdown - Hypotension - Hyperreflexia - Tachypnea

- Tachypnea RATIONALE: When using the airway, breathing, & circulation approach to client care, the nurse's priority finding is the toddler's tachypnea. Tachypnea is a result of the kidneys being unable to excrete hydrogen ions & produce bicarbonate, which lead to metabolic acidosis.

A nurse is assessing the vital signs of a 10-year-old child following a burn injury. The nurse should identify that which of the following findings is an indication of early septic shock? - Blood pressure 130/90 mmHg - Heart rate 60/min - Temperature 39.1 C (102.4 F) - Urinary output 100 ml/hr

- Temperature 39.1 C (102.4 F) RATIONALE: The nurse should identify that a temperature 39.1 C (102.4 F) is above the expected reference range of 37 to 37.5 C (98.6 to 99.5 F) for a 10-year-old child. The nurse should expect a child who has early septic shock to have a fever and chills.

A school nurse is assessing an adolescent who has scoliosis. Which of the following findings should the nurse expect? - Increase in anterior convexity of the lumbar spine - Increased curvature of the thoracic spine - Lateral flexion of the neck - A unilateral rib hump

- A unilateral rib hump RATIONALE: When assessing an adolescent for scoliosis, the school nurse should expect to see a unilateral rib hump with hip flexion. This results from a lateral S- or C-shaped curvature to the thoracic spine resulting in asymmetry of the ribs, shoulders, hips, or pelvis. Scoliosis can be the result of a neuromuscular or connective tissue disorder, or it can be congenital in nature.

A nurse is caring for a toddler who has spastic (pyramidal) cerebral palsy. Which of the following findings should the nurse expect? (Select all that apply). - Negative Babinski reflex - Ankle clonus - Exaggerated stretch reflexes - Uncontrollable movements of the face - Contractures

- Ankle clonus RATIONALE: The nurse should expect a child who has spastic cerebral palsy to exhibit ankle clonus, which is a rhythmic reflex tremor when the foot is dorsiflexed. - Exaggerated stretch reflexes RATIONALE: The nurse should expect a child who has spastic cerebral palsy to exhibit spasticity or exaggerated stretch reflexes - Contractures RATIONALE: The nurse should expect a child who has spastic cerebral palsy to exhibit contractures due to the tightening of the muscles.

A nurse is caring for a school-age child who is in Buck's traction following a leg fracture 24 hr ago. Which of the following actions should the nurse take? - Change the child's position every 2 hr - Clean the peripheral pin sites with chlorhexidine solution every 4 days - Assess peripheral pulses once every 4 hours - Ensure that the HOB is elevated to a 90 degree angle

- Assess peripheral pulses once every 4 hours RATIONALE: Buck's traction is a type of skin traction that can be used to immobilize extremities prior to surgery. The nurse should provide frequent neurovascular checks at least every 4 hr after the first 24 hr of placement in Buck's traction. The nurse should monitor and report signs of neurovascular impairment in the extremities such as cyanosis, edema, pain, absent pulses, and tingling.

A school nurse is assessing an adolescent who has multiple burns in various stages of healing. Which of the following behaviors should the nurse identify as a possible indication of physical abuse? - Expresses a reluctance to leave home - Provides a detailed description of how the burns occurred - Denies discomfort during assessment of injuries - Describes strong relationships with peers

- Denies discomfort during assessment of injuries RATIONALE: The nurse should suspect child maltreatment in the form of physical abuse if the adolescent has a blunted response to painful stimuli or injury.

A nurse is caring for a school-age child who is receiving a blood transfusion. Which of the following manifestations should alert the nurse to a possible hemolytic transfusion reaction? - Laryngeal edema - Flank pain - Distended neck veins - Muscular weakness

- Flank pain RATIONALE: The nurse should recognize that flank pain is caused by the breakdown of RBCs and is an indication of a hemolytic reaction to the blood transfusion.

A nurse is caring for a school-age child who has experienced a tonic-clonic seizure. Which of the following actions should the nurse take during the immediate postictal period? - Place the child in a side-lying position - Delay documentation until the child is fully alert - Give the child a high-carbohydrate snack - Administer an oral sedative to the child

- Place the child in a side-lying position RATIONALE: The nurse should place the child in a side-lying position to prevent aspiration.

A nurse is assessing a 4-year-old child at a well-child visit. Which of the following developmental milestones should the nurse expect to observe? - Identifies right from left hand - Uses a utensil to spread butter - Cuts an outlined shape using scissors - Draws a stick figure with seven body parts

- Cuts an outlined shape using scissors RATIONALE: The nurse should recognize that an expected developmental milestone of a 4-year-old child is using scissors to cut out a shape.

A nurse is assessing a 3-year-old toddler at a well-child visit. Which of the following manifestations should the nurse report to the provider? - Blood pressure 90/50 mmHg - Respiratory rate 45/min - Weight 14.5 kg (32 lb) - Heart rate 110/min

- Respiratory rate 45/min RATIONALE: The nurse should identify that a respiratory rate of 45/min is above the expected reference range of 20 to 25/min for a 3-year-old toddler and can indicate respiratory dysfunction and acute respiratory distress. Therefore, the nurse should report this finding to the provider.

A school nurse is preparing to administer atomoxetine 1.2 mg/kg/day PO to a school-age child who weighs 75 lbs. Available is atomoxetine 40 mg/capsule. How many capsules should the nurse administer per day?

- 1 capsule RATIONALE: 75 lb x 1 kg/2.2 lb x 1.2mg/1 kg x 1 capsule/40 mg = 1 capsule

The nurse is caring for the child 4 days after admission. After reviewing the child's assessment, which of the following findings should the nurse address first? Complete the following sentence by using the list of options. 1) The nurse should first address the client's ________ - Temperature - Saturate dressing - Urine output - Blood pressure - Respiratory status 2) followed by the client's ________ - Pain - Sensorium - Nutrition - Drainage on dressing - Fluid status

- Temperature RATIONALE: When using the urgent vs. nonurgent approach to client care, the nurse should determine that an increased temperature is a priority finding, because it can indicate an infection and sepsis. Wound sepsis is most likely to occur between the 3rd and 5th day after a burn. Therefore, the nurse should first address the child's temperature. - Pain RATIONALE: When using the urgent vs. nonurgent approach to client care, the nurse should determine that an 8 out of 10 pain rating on the FACES scale is a priority finding and should be addressed next. Severe pain impacts the stress response, which can lead to complications and adversely affect healing.

A nurse is caring for a preschooler who has been receiving IV fluids via a peripheral IV catheter. When preparing to discontinue the IV fluids and catheter, which of the following actions should the nurse plan to take? (Move the steps into the box on the right, placing them in order of performance. Use all steps.) - Remove tape securing the catheter - Occlude the IV tubing - Turn off the IV pump - Apply pressure over the catheter insertion site

- Turn off the IV pump - Occlude the IV tubing - Remove tape securing the catheter - Apply pressure over the catheter insertion site RATIONALE: First, the nurse should turn off the IV pump. Next, the nurse should occlude the IV tubing, and then remove the tape securing the catheter. Last, the nurse should apply pressure over the catheter insertion site.

A nurse is providing dietary teaching to the parent of a school-age child who has celiac disease. The nurse should recommend that the parent offer which of the following foods to the child? - Wheat crackers - Rye bread - Barley soup - White rice

- White rice RATIONALE: The nurse should recommend that the parent offer white rice to the child because it is a gluten-free food. The nurse should instruct the parent that the child will remain on a lifelong gluten-free diet and the child should not consume oats, rye, barley, or wheat, and sometime lactose deficiency can be secondary to this disease.

The nurse is continuing to care for the child. After examining the child during hydrotherapy, the provider enters prescriptions into the child's medical record. For each potential provider prescription, specify if the potential prescription is anticipated or contraindicated for the child. - Change the morphine route to family-controlled analgesia via a PCA pump. - Obtain a wound culture - Place the child on a pressure-reduction mattress - Limit protein intake

Anticipated: - Change the morphine route to family-controlled analgesia via a PCA pump. RATIONALE: A pain rating of 8 indicates severe pain. The use of a PCA pump should increase the effectiveness of pain management during movement and procedures. The nurse should teach the child's primary caregiver about the use of the PCA pump. - Obtain a wound culture RATIONALE: The child has an elevated temperature and malodorous green wound drainage. The nurse should obtain a wound culture to determine the causative organism and an antibiotic should be administered. - Place the child on a pressure-reduction mattress RATIONALE: The child has developed a stage 1 pressure injury on their occiput. A pressure-reduction mattress can help prevent further tissue injury. Contraindicated: - Limit protein intake RATIONALE: Children who have major burns require a high-protein, high-calorie diet to help with wound healing. The nurse should provide high-protein snacks to the child between meals.

The nurse is providing discharge teaching to the child and their parent 36 days after admission. Select 6 statements by the parent that indicate an understanding of the discharge teaching. - "I will give my child hydroxyzine to prevent bacterial infection." - "I should apply a moisturizer to the scar tissue." - "I will use a measured spoon or medicine cup to give my child hydroxyzine." - "I can give my child hydroxyzine every 6 hours as needed." - "Puppet play can be helpful for my child." - "I should avoid giving hydroxyzine at bedtime." - "I will avoid massaging the scar tissue." - "My child is too young to be concerned about their body image." - "I need to assess for any redness or open skin areas before applying my child's left arm splint." - "My child will need to use a compression garment to decrease blood supply to the scarred tissue."

- "I should apply a moisturizer to the scar tissue." RATIONALE: Frequent application of a non-perfume moisturizer should be applied to the scar tissue to help reduce itching the child might experience. - "I will use a measured spoon or medicine cup to give my child hydroxyzine." RATIONALE: All liquid medications should be administered with a measured spoon or cup to provide an accurate amount of the prescribed dose of medication. - "I can give my child hydroxyzine every 6 hours as needed." RATIONALE: Hydroxyzine is administered every 6 to 8 hours each day as needed. - "Puppet play can be helpful for my child." RATIONALE: Preschoolers engage in imaginative play. The use of puppets will encourage the child to express their feelings through imaginary play. - "I need to assess for any redness or open skin areas before applying my child's left arm splint." RATIONALE: It is important that the child's skin be assessed for redness, open areas, or blisters prior to putting on a splint. The splint is used to prevent contractures of the extremities and promote normal alignment during the healing process. Because the splint might be worn for a long period of time, the child's growth might cause the splint to not fit properly and can cause a pressure injury. - "My child will need to use a compression garment to decrease blood supply to the scarred tissue." RATIONALE: Using the compression garment on the scar tissue decreases the blood supply to avoid nourishing the hypertrophic tissue. It also forces the collagen into a more normal alignment. Compression garments are worn during the healing of the burned tissue and should be worn as much as possible.

A nurse in an emergency department is performing a physical assessment on a 2-week-old male newborn. Which of the following findings is the priority for the nurse to report to the provider? - Excoriated scrotal area - Multiple capillary hemangiomas - Depressed posterior fontanel - Substernal retractions

- Substernal retractions RATIONALE: When using the airway, breathing, & circulation approach to client care, the nurse should determine that the priority finding to report to the provider is substernal retractions. This finding indicates the newborn is experiencing increased respiratory effort, which could quickly progress to respiratory failure.

A nurse is teaching the guardian of a 6-month-old infant about care seat use. Which of the following statements by the guardian indicates an understanding of the teaching? - "I should secure the car seat using lower anchors and tethers instead of the seat belt." - "I should position the car seat harness 1 inch above my baby's shoulders." - "I will make sure that the car seat is placed at a 90-degree angle." - "I will pad my baby's car seat with a blanket for traveling long distances."

- "I should secure the car seat using lower anchors and tethers instead of the seat belt." RATIONALE: Low anchors and tethers, or the LATCH child safety seat system, should be used to secure an infant's care seat in the vehicle. This system provides anchors between the front cushion and the back rest for the car seat. Therefore, if this system is available, the seat belt does not have to be used.

A nurse is teaching a school-age child who has a new diagnosis of type 1 diabetes mellitus. Which of the following statements by the child indicates an understanding of the teaching? - "I will puncture the pad of my finger when I am testing my blood glucose." - "I will give myself a shot of regular insulin 30 minutes before I eat breakfast." - "I will eat a snack of 5 grams of carbohydrates if my blood glucose is low." - "I will decrease the amount of fluids I drink when I am sick."

- "I will give myself a shot of regular insulin 30 minutes before I eat breakfast." RATIONALE: The child should administer regular insulin 30 minutes before meals so that the onset coincides with food intake.

The nurse is caring for the child 14 days after admission. The child has returned to the unit following the procedure. Which of the following actions should the nurse take? Select all that apply. - Monitor SaO2 every 2 hr - Provide 100% oxygen via face mask - Check anterior neck and chest dressing for bleeding - Replace dressing on the left thigh - Place a warm blanket on the child - Keep the child's head in a neutral position

- Provide 100% oxygen via face mask RATIONALE: The nurse should provide 100% oxygen via face mask to the child because of their SaO2 and respiratory rate. The SaO2 should be maintained at 95% or higher and if the SaO2 falls below 95%, supplemental oxygen should be initiated. - Check anterior neck and chest dressing for bleeding RATIONALE: Upon return from the procedure, all surgical dressings should be assessed for drainage and to ensure the dressing is intact. - Place a warm blanket on the child RATIONALE: The child is exhibiting hypothermia. It is important for the child to have a stable body temperature because vasoconstriction can diminish blood flow to the surgical sites and impair healing. - Keep the child's head in a neutral position RATIONALE: The child's head should be kept in a neutral alignment to prevent hyperextension or hyperflexion and to prevent graft loss.

A nurse in an emergency department is caring for a 4-year-old child who was rescued from a home fire by emergency medical services. Which of the following potential provider prescriptions should the nurse identify as anticipated or contraindicated? For each potential provider's prescription, click to specify if the potential prescription is anticipated or contraindicated for the child. - Apply sterile gauze soaked with cool 0.9% sodium chloride to the burn areas - Insert an indwelling urinary catheter - Provide 100% oxygen via face mask - Weigh the child

Contraindicated: - Apply sterile gauze soaked with cool 0.9% sodium chloride to the burn areas RATIONALE: Applying sterile gauze soaked with cool 0.9% sodium chloride to a child who has 18% TBSA might cause hypothermia. The nurse should cover the burn with a clean, dry cloth to prevent contamination and hypothermia. Anticipated: - Insert an indwelling urinary catheter RATIONALE: Inserting an indwelling urinary catheter is essential and allows for accurate measurement of urine output. Urine output is an indicator of the fluid status of the child. A child who has major burns will lose a significant amount of fluid due to increased permeability, which increases the risk for hypovolemic shock. It is important to maintain accurate hourly I&O to manage fluid replacement. - Provide 100% oxygen via face mask RATIONALE: Upon admission to the emergency department, the nurse should recognize the need to provide 100% oxygen via face mask is an essential prescription. The child's SaO2 is below the expected reference range and their respiratory rate is increased. - Weigh the child RATIONALE: The nurse should recognize the need to weigh the child as essential. Children of the same age weigh different amounts. The amount of fluid resuscitation and medication a pediatric patient receives is based on their weight.

The nurse is caring for the child 4 days after admission. After reviewing the child's assessment, which of the following findings should the nurse address first? Complete the following sentence by using the lists of options. The nurse should first address the client's __________ - Temperature - Saturated dressing - Urine output - Blood pressure - Respiratory status followed by the client's __________. - Pain - Sensorium - Nutrition - Drainage on dressing - Fluid status

The nurse should first address the client's __________ - Temperature RATIONALE: When using the urgent vs. non urgent approach to client care, the nurse should determine that an increased temperature is a priority finding, because it can indicate an infection & sepsis. Wound sepsis is most likely to occur between the 3rd & 5th day after a burn. Therefore, the nurse should first address the child's temperature. followed by the client's __________. - Pain RATIONALE: When using the urgent vs. non urgent approach to client care, the nurse should determine that an 8 out of 10 pain rating on the FACES scale is a priority finding and should be addressed next. Severe pain impacts the stress response, which can lead to complications and adversely affect healing.

A nurse is reviewing the laboratory report of an infant who is receiving treatment for severe dehydration. The nurse should identify that which of the following laboratory values indicates effectiveness of the current treatment? - Potassium 2.9 mEq/L - Sodium 140 mEq/L - Urine specific gravity 1.035 - BUN 25 mg/dL

- Sodium 140 mEq/L RATIONALE: The nurse should identify that a sodium level of 140 mEq/L is within the expected reference range of 134 to 150 mEq/L and indicates that the current treatment regimen the infant is receiving for dehydration is effective.

A nurse is teaching the parent of an infant who has a Pavlik harness for the treatment of developmental dysplasia of the hip. The nurse should identify that which of the following statements by the parent indicates an understanding of the teaching? - "I should remove the harness at night to allow my infant to stretch her legs." - "I will need to adjust the straps of the harness once each week." - "I should apply baby powder to my infant's skin twice daily." - "I will place my infant's diapers under the harness straps."

- "I will place my infant's diapers under the harness straps." RATIONALE: To prevent soiling of the harness, the parent should apply the infant's diaper under the straps.

A hospice nurse is caring for a preschooler who has a terminal illness. One of the preschooler's parents tells the nurse that they cannot cope anymore and are thinking about moving out of the house. Which of the following statements should the nurse make? - "It is important that you provide emotional support for your family at this time." - "You have to do what you feel is best. Everything will turn out fine." - "i know how you feel. This is an extremely stressful time for your family." - "Let's talk about some of the ways you have handled previous stressors in your life."

- "Let's talk about some of the ways you have handled previous stressors in your life." RATIONALE: This statement offers a general lead to allow the parent to express their feelings and previous actions when faced with stressful situations. It also helps the parent to focus on ways that they can cope with the current situation.

A nurse in a provider's office is caring for a preschooler. Which of the following statements by a guardian indicate that the discharge teaching was effective? - "We should apply a skin emollient immediately after bathing our child." - "We should keep our child's fingernails trimmed short." - "We should rub the sores vigorously to remove scabs." - "We should allow our child to take a bubble bath prior to bed." - "We should use a mild detergent for our laundry." - "We should apply a large amount of the ointment to the sores."

- "We should apply a skin emollient immediately after bathing our child." RATIONALE: 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." RATIONALE: 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." RATIONALE: The use of mild detergents for laundry helps prevent allergens and itching. Therefore, this statement by the guardian indicates the teaching has been effective.

A nurse is caring for a 15-year-old client who is married and is scheduled for a surgical procedure. The client asks, "Who should sign my surgical consent?" Which of the following responses should the nurse make? - "You can sign the consent form because you are married." - "Your spouse should sign the consent form for you." - "Your parent should sign the consent form for you." - "You can appoint a legal guardian to sign the consent form."

- "You can sign the consent form because you are married." RATIONALE: The nurse should inform the adolescent that marriage gives adolescents the legal right to consent to surgical procedure and sign other legal documents that they would not otherwise be able to sign due to their age.

A nurse is caring for a preschooler whose father is going home for a few hours while another relative stays with the child. Which of the following statements should the nurse make to the child when their father will return? - "Your daddy will be back at 7 p.m." - "Your daddy will be back after he takes care of your brother." - "Your daddy will be back in the morning." - "Your daddy will be back after you eat."

- "Your daddy will be back after you eat." RATIONALE: Preschoolers make sense of time best when they can associate it with an expected daily routine, such as meals and bedtime. Therefore, the child comprehends best when it is explained to them in relation to an event they are familiar with, such as eating.

A nurse is receiving change-of-shift report for four children. Which of the following children should the nurse see first? - A school-age child who has sickle cell anemia & reports decreased vision in the left eye - A school-age child who cystic fibrosis & a frequent nonproductive cough - A preschooler who has asthma & a peak flow meter reading in the green zone - A adolescent who has meningitis & reports sensitivity to lights & noise

- A school-age child who has sickle cell anemia & reports decreased vision in the left eye RATIONALE: When using the urgent vs. nonurgent approach to client care, the nurse should determine the priority finding is a report of decreased vision in the left eye. This finding indicates that the child is experiencing a vaso-occlusive crisis & should be reported to the provider immediately. Therefore, the nurse should see this child first.

A nurse on a pediatric unit is caring for a school-age child. After reviewing the information in the child's medical record, which of the following findings should the nurse report to the provider? Select the 4 findings that the nurse should report to the provider. - Arterial blood gases - Cardiovascular assessment - WBC count - Hemoglobin - Oxygen saturation level - Respiratory assessment

- Arterial blood gases RATIONALE: 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. - WBC count RATIONALE: 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 these findings to the provider. - Oxygen saturation level RATIONALE: The child's oxygen saturation level has decreased below the expected reference range despite the use of supplemental oxygen. Therefore, the nurse should report these findings to the provider. - Respiratory assessment RATIONALE: 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 a school-age child who is receiving cefazolin via intermittent IV bolus. The child suddenly develops diffuse flushing of the skin and angioedema. After discontinuing the medication infusion, which of the following medications should the nurse administer first? - Prednisone - Epinephrine - Diphenhydramine - Albuteral

- Epinephrine RATIONALE: The child is most likely experiencing an anaphylactic reaction to the cefazolin. According to evidence-based practice, the nurse should first administer epinephrine to treat the anaphylaxis. Epinephrine is a beta adrenergic agonist that stimulates the heart, causes vasoconstriction of blood vessels in the skin and mucous membranes, and triggers bronchodilation in the lungs.

A nurse in an emergency department is caring for a school-age child who has appendicitis and rates their abdominal pain as 7 on a scale of 0 to 10. Which of the following actions should the nurse take? - Instill a 500 mL tap water enema - Give morphine 0.05 mg/kg IV - Administer polyethylene glycol 1 g/kg PO - Apply a heating pad to the child's abdomen

- Give morphine 0.05 mg/kg IV RATIONALE: A pain level of 7 on a scale of 0 to 10 is considered severe. The nurse should administer a analgesic medication for pain relief.

A nurse is caring for an infant who has respiratory syncytial virus (RSV). Which of the following actions should the nurse implement for infection control? - Have a designated stethoscope in the infant's room - Place the infant in a room equipped with negative airflow - Administer palivizumab as prescribed for the infant - Remove gloves after leaving the infant's room

- Have a designated stethoscope in the infant's room RATIONALE: The nurse should initiate droplet precautions for an infant who has RSV because the virus is spread by direct contact with respiratory secretions. Therefore, designated equipment, such as a blood pressure cuff and a stethoscope, should be placed in the infant's room.

A nurse is reviewing the laboratory report of a school-age child who is experiencing fatigue. Which of the following findings should the nurse recognize as an indication of anemia? - Hematocrit 28% - Hemoglobin 13.5 g/dL - WBC count 8,000/mm3 - Platelets 250,000/mm3

- Hematocrit 28% RATIONALE: The nurse should recognize that this hematocrit level is below the expected reference range of 32% to 44% for a school-age child. The child can exhibit fatigue, lightheadedness, tachycardia, dyspnea, and pallor due to the decreased oxygen-carrying supply.

A nurse is reviewing the lumbar puncture results of a school-aged child who is suspected of having bacterial meningitis. Which of the following findings should the nurse identify as an indication of bacterial meningitis? - Decreased CSF - Decreased WBC count - Increased protein concentration - Increased glucose level

- Increased protein concentration RATIONALE: The nurse should identify that an increased protein concentration in the spinal fluid is a finding that can indicate bacterial meningitis.

A nurse in an emergency department is caring for a 4-year-old child who was rescued from a home fire by emergency medical services. The nurse should identify that which of the following findings require immediate follow-up? Select the 3 findings that require immediate follow-up. - Child is awake and crying - Partial- and full-thickness burns to the left upper anterior chest and neck - Non-productive cough - SaO2 89% on room air - Heart rate 150/min - Temperature 37.7 C (99.9 F) - Blood pressure 100/52 mmHg

- Partial- and full-thickness burns to the left upper anterior chest and neck RATIONALE: Airway, breathing, and circulation are the immediate concerns. Burns to the chest and neck require immediate follow-up due to a concern for inhalation injury, In addition, the edema of the tissue in the neck can compromise the airway and severe burns to the chest can impede the child's ability to expand their chest during inspiration, causing respiratory distress. - SaO2 89% on room air RATIONALE: Airway, breathing, and circulation are the immediate concerns. The nurse should immediately follow-up on the low O2 saturation level. Hypoxia can be a manifestation of respiratory distress or shock. Therefore, this finding needs immediate attention. - Heart rate 150/min RATIONALE: Airway, breathing, and circulation are the immediate concerns. The nurse should immediately follow-up on the child's increased heart rate. Tachycardia is a manifestation of shock. Children with major burns can develop hypovolemic shock due to fluid loss.

A nurse is caring for a school-age child who is receiving chemotherapy and is severely immunocompromised. Which of the following actions should the nurse take? - Use surgical asepsis when providing routine care for the child - Administer the measles, mumps, rubella (MMR), vaccine to the child - Screen the child's visitors for indications of infection - Infuse packed RBCs

- Screen the child's visitors for indications of infection RATIONALE: A child who is severely immunocompromised is unable to adequately respond to infectious organisms, resulting in the potential for overwhelming infection. Therefore, the nurse should screen the child's visitors for indications of infection.

A nurse is caring for an adolescent who received a kidney transplant. Which of the following findings should the nurse identify as an indication the adolescent is rejecting the kidney? - Negative leukocyte esterase - Serum creatinine 3.0 mg/dL - Negative urine protein - Urine output 40 mL/hr

- Serum creatinine 3.0 mg/dL RATIONALE: Creatinine is a byproduct of protein metabolism and is excreted from the body through the kidneys. An elevated serum creatinine level, therefore, can be an indication that the kidneys are not functioning. The nurse should identify that the adolescent's serum creatinine level is higher than the expected reference range of 0.4 to 1.0 mg/dL for an adolescent and can indicate rejection of the kidney.

A nurse on a pediatric unit is admitting a preschooler. 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. 1) The nurse should identify that the child is at risk for developing ________ - Splenomegaly - Acute poststreptococcal glomerulonephritis (APSGN) - Dysrhythmias 2) as evidenced by ______________ - Positive mononucleosis rapid test - Urinary output - Cardiovascular assessment

- Splenomegaly RATIONALE: 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 RATIONALE: 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 auscultating the lungs of an adolescents who has asthma. The nurse should identify the sound as which of the following? - Biot respiration - Cheyne-Stokes respiration - Tachypnea - Bradypnea

- Tachypnea RATIONALE: The nurse should identify the sound heard during the auscultation as tachypnea, which is a rapid, regular breathing pattern. This breathing pattern often occurs with anxiety, fever, metabolic acidosis, or severe anemia.