NCLEX pediatrics
Obtains a weight A health care provider prescribes an intravenous (IV) solution of 5% dextrose and half-normal saline (0.45%) with 40 mEq of potassium chloride for a child with hypotonic dehydration. The nurse performs which priority assessment before administering this IV prescription?
Checks the amount of urine output
Cracked lips The nurse assists with admitting a child with a diagnosis of acute stage Kawasaki disease. When obtaining the child's medical history, which manifestation is likely to be noted?
Conjunctival hyperemia
Have the child sit up and lean forward. A child has epistaxis. The nurse understands that which treatment is appropriate for epistaxis?
Have the child sit up and lean forward.
In a supine, side-lying position The nurse is caring for a hospitalized infant with a diagnosis of bronchiolitis. The nurse places the infant in which position?
With the head and chest at a 30-degree angle, with the neck slightly extended
The entire bone fractured straight across The nurse is assigned to care for a child with a compound (open) fracture of the arm that occurred as a result of a fall. The nurse plans care knowing that this type of fracture involves which specific characteristic?
A greater risk of infection than a simple fracture
Encourage limited activity and provide safety measures. The nurse is assisting in developing a plan of care for a child diagnosed with acute glomerulonephritis. The nurse should include which intervention in the plan of care?
Encourage limited activity and provide safety measures.
"Children always look a little bit fat, so don't be concerned." The nurse is providing information to the mother of a child with nephrotic syndrome regarding the edematous appearance of the child. Which statement should the nurse make to the mother?
"The fluid retention should be controlled by medication and diet."
"Frequent hand washing is important." The nurse reinforces home-care instructions to the parents of a child with hepatitis regarding the care of the child and the prevention of the transmission of the virus. Which statement by a parent indicates a need for further teaching?
"I need to provide a well-balanced, high-fat diet to my child."
"I should encourage fluid intake." The nurse has reinforced discharge instructions to the mother of an 18-month-old child following surgical repair of hypospadias. Which statement by the mother indicates a need for further teaching?
"I should carry my child by straddling the child on my hip."
"I need to watch for diarrhea, so my child does not get dehydrated." The nurse is providing discharge instructions to the parents of a 14-year-old child who is undergoing radiation for Hodgkin's disease. Which statement by a parent indicates the need for further teaching?
"I will need to keep my child's skin from flaking, so we will be allowing showers every 2 or 3 days."
Document the findings. The nurse is caring for a hospitalized infant and is monitoring for increased intracranial pressure (ICP). The nurse notes that the anterior fontanel bulges when the infant cries. Based on this finding, which action should the nurse take?
Document the findings.
Ganciclovir A child is hospitalized with Rocky Mountain spotted fever (RMSF). The health record reveals documentation that the child was bitten by a tick 2 weeks ago. The child presents with complaints of headache, fever, and anorexia, and the nurse notes a rash on the palms of the hands and soles of the feet. The nurse reviews the primary health care provider's prescriptions and anticipates that which medication should be prescribed?
Doxycycline
Each gram of diaper weight is equivalent to 0.5 mL of urine. The nurse is monitoring for fluid volume deficit in an infant who is vomiting and having diarrhea. The nurse weighs the infant's diaper after each voiding and stool and carefully calculates fluid volume based on which knowledge?
Each gram of diaper weight is equivalent to 1 mL of urine.
Gastric contents regurgitate back into the esophagus. A newborn infant is diagnosed with gastroesophageal reflux (GER). The mother of the infant asks the nurse to explain the diagnosis. The nurse plans to base the response on which description of this disorder?
Gastric contents regurgitate back into the esophagus.
Pupillary reaction The nurse is caring for a 9-year-old child with leukemia who is hospitalized for the administration of chemotherapy. The nurse monitors the child for central nervous system (CNS) involvement by checking which response?
Level of consciousness (LOC)
Observe for bleeding. The nurse is caring for a child with a platelet disorder and should expect which prescriptions from the primary health care provider? Select all that apply.
Observe for bleeding. Encourage the child to rest. Assist the registered nurse (RN) with blood transfusions.
Signs of hyperglycemia The nurse reviews the plan of care for a child with Reye's syndrome. Which priority complication should the nurse plan to monitor?
Signs of increased intracranial pressure
Weighing the diapers A nursing student is assigned to care for an infant with a diagnosis of heart failure (HF). The student develops a plan of care for the child that is focused on monitoring for fluid overload. The student plans to best assess the urine output of the infant by taking which action?
Weighing the diapers
Assess the child's growth status. A mother brings her 5-month-old daughter into the pediatrician's office with complaints that the child has been vomiting during feedings. The mother also states that the child is sometimes very fussy. Which should be the nurse's initial action?
Obtain a complete history of the child's feeding habits.
HIV primarily attacks the hematological system. A nursing student is asked to discuss human immunodeficiency virus (HIV) during a clinical conference. The nursing student should include which correct item in the discussion?
HIV virus attacks the immune system by destroying T lymphocytes.
Damage to the midbrain The nurse is preparing to care for a child with a head injury. On review of the records, the nurse notes that the primary health care provider has documented decorticate posturing. The nurse plans care, knowing that this type of posturing indicates which finding?
Dysfunction in the cerebral hemisphere
"I will have to give my child a lot of medications." A nurse discussing options with a mother of a child with cystic fibrosis (CF) asks if she understands the education. Which statement by the mother indicates a need for further teaching?
"I can give my child whatever foods he likes to eat, since he gets enzymes anyway."
"I will not allow my child to swim in lake water." The nurse reinforces discharge instructions to the mother of a child following a myringotomy with insertion of tympanostomy tubes. Which statement by the mother indicates a need for further teaching?
"I need to be sure my child uses soft tissues to blow his nose."
Place the child on a wheeled scooter board. A child with cerebral palsy (CP) is working to achieve maximum potential for locomotion, self-care, and socialization in school. To meet these goals, which action should the nurse take when working with the child?
A bottle of sterile normal saline
Give the child 6 oz of a regular cola drink. An adolescent with diabetes mellitus is attending gym class and suddenly becomes flushed and complains of dizziness and a headache. The gym teacher quickly takes the adolescent to the school nurse's office. The nurse obtains a blood glucose level, and the results indicate a level of 65 mg/dL. Which initial nursing intervention is appropriate?
Give the child 6 oz of a regular cola drink.
Heart rate The nurse is caring for a child who was burned in a house fire. The nurse assists in developing a plan of care for monitoring the child during the treatment for burn shock. The nurse identifies which assessment as providing the most accurate guide to determine the adequacy of fluid resuscitation?
Level of consciousness
The reticuloendothelial system is affected. A nursing student is asked to discuss the pathophysiology related to childhood leukemia during a clinical conference and reviews the planned presentation with the nursing instructor. The nursing instructor advises the student to review the disorder before the clinical conference if the student states that which is associated with this type of cancer?
Reed-Sternberg cells are found on biopsy.
The child is awake, alert, and interacting with the environment. The nurse is reviewing a chart of a child with a head injury. The nurse notices that the level of consciousness has been documented as obtunded. Which observation should the nurse expect to make during data collection of the child?
The child sleeps unless aroused and, once aroused, interacts poorly with the environment.
"The disease is caused by a virus." Several children have contracted measles (rubeola) in a local school, and the nurse provides information to the mothers of the children about this communicable disease. Which statement by a mother indicates a need for further teaching?
"The symptoms increase in severity after the rash appears."
Spray the home's furniture and beds with insecticide. The nurse is reinforcing instructions to the mother of a preschool child who was recently diagnosed with pediculosis capitis (head lice). Which item should be included in discussions to prevent a reinfestation?
Seal nonwashable items in a plastic bag for 2 to 3 weeks in a warm place if they cannot be vacuumed or dry cleaned.
"I hear that the side effects of the medication that my child will be on can cause overeating." The nurse provides homecare instructions to the parent of a child with attention deficit hyperactivity disorder regarding behavioral therapy interventions. Which statement by the parent indicates a need for further teaching?
"I hear that the side effects of the medication that my child will be on can cause overeating."
"The child is complaining of pain in her throat." The nurse is caring for a child who returned from tonsillectomy surgery 30 minutes ago and enters the room for routine monitoring to see the child repeatedly and rapidly swallowing. Using the SBAR (Situation, Background, Assessment, Recommendation) technique, which statements and/or questions should the nurse include in the conversation with the primary health care provider? Select all that apply.
"Could you please come assess the child as soon as possible?" "I am concerned that the child is bleeding from the surgical sites." "Two minutes ago, I entered the child's room for routine monitoring and observed that she was swallowing repeatedly and rapidly." "Hello, this is Maria on the third floor. I am the nurse caring for Ella Smith, the 6-year-old child in room 342 who returned 30 minutes ago from a tonsillectomy."
"This brace will correct my curve." The nurse has reinforced prior teaching of a school-age child who was given a brace to wear for the treatment of scoliosis. The child needs further teaching if which statement is made?
"This brace will correct my curve."
"The impetigo is extremely contagious." A mother brings her child to the health care clinic because the child has developed lesions located around the mouth and nose, and mild impetigo is diagnosed. The nurse reinforces instructions to the mother regarding care of the child. Which statement by the mother indicates the need for further teaching?
"My child will need to be treated with oral antibiotics."
"Hot or cold packs will assist in reducing discomfort." The nurse is reinforcing instructions to the mother of a child with juvenile idiopathic arthritis regarding measures to take if a painful exacerbation of the disease occurs. Which statement by the mother indicates the need for further teaching?
"The full range-of-motion (ROM) exercises must be performed every day, even during the exacerbations."
Monitor the infant for a fever. A 6-month-old infant receives a diphtheria, tetanus, and acellular pertussis (DTaP) immunization at the well-baby clinic. The parent returns home and calls the clinic to report that the infant has developed swelling and redness at the site of injection. Which instruction by the nurse is appropriate?
Apply an ice pack to the injection site.
Excessive oral secretions The nurse is reviewing the health record of an infant with a diagnosis of gastroesophageal reflux. Which signs/symptoms of this disorder should the nurse expect to note documented in the record?
Hiccupping and spitting up after a meal
"I will inspect the skin under the brace for redness or breakdown." The nurse reinforces home care instructions to the parents of a child with a brace for scoliosis. Which statement by a parent indicates a need for further teaching?
"I understand that my child needs to wear this brace for 12 hours a day."
"It can cause death if large amounts of tissue are involved." A nursing student is caring for a child with increased intracranial pressure. On review of the chart, the student nurse notes that a transtentorial herniation has occurred. A nursing instructor asks the student about this type of herniation. Which statement by the student indicates a need for further research about this condition?
"It involves only the anterior portions of the client's brain."
A cooling blanket The nurse is assisting in preparing to care for a child with a brain tumor who will be returning from the recovery room following debulking of the tumor. Which item should the nurse place at the bedside in preparation for the child's return from surgery?
A cooling blanket
Check the blood pressure. The nurse is caring for a newborn with spina bifida (myelomeningocele type) who is scheduled for the removal of the gibbus (sac on the back filled with cerebrospinal fluid, meninges, and some of the spinal cord). Which is the priority nursing action in the preoperative period?
Maintain moisture of the normal saline dressing on the gibbus area.
Rice The nurse has reinforced dietary instructions to the mother of a child with celiac disease. The nurse determines that the mother understands the dietary instructions if she indicates eliminating which products? Select all that apply.
Oatmeal Rye crackers Wheat bread
Fatigue The nurse is reinforcing the teaching to parents of a diabetic child about the signs/symptoms of hypoglycemia. Which signs/symptoms should the nurse include when reinforcing the teaching? Select all that apply.
Sweating Dizziness Trembling
Wound care The nurse is assisting in planning discharge instructions to the mother of a child following orchiopexy, which was performed on an outpatient basis. Which is the priority in the plan of care?
Wound care
The harness must be worn 8 hours a day. The nurse reinforces instructions to the parents of an infant with hip dysplasia regarding care of the Pavlik harness. Which instruction provided by the nurse is accurate?
The harness needs to be removed to check the skin and for bathing.
"I need to use proper hand-washing techniques." The nurse reinforces instructions to the parents of a child with leukemia regarding measures related to monitoring for infection. Which statement by the parents indicates the need for further teaching?
"I need to take my child's rectal temperature daily."
"I will get a flu shot and I will have my child get a flu shot too." The nurse is reviewing instructions to a parent of a 6-year-old on how to prevent influenza. Which statement by the parent indicates a need for further teaching?
"I will not let my child play with other children who have the flu unless they are taking acetaminophen."
The 6-month old with bronchopulmonary dysplasia The nurse is caring for a 4-month-old infant with respiratory syncytial virus (RSV). Several clients are being admitted to the unit and assignments are being made. The nurse should question being assigned which newly admitted clients? Select all that apply.
The 6-month old with bronchopulmonary dysplasia The 1-year-old client taking corticosteroids
Drink plenty of fluids. A child with sickle cell anemia is being discharged after treatment for a crisis. Which instructions should the nurse reinforce to prevent another crisis from occurring? Select all that apply.
Drink plenty of fluids. Report a sore throat immediately. Wash hands before meals and after playing.
Encourage naps. The nurse caring for a child with aplastic anemia is reviewing the laboratory results and notes a white blood cell (WBC) count of 6000 mm3 (6 × 109/L) and a platelet count of 20,000 mm3 (20 × 109/L). Which nursing intervention should be incorporated into the plan of care?
Encourage quiet play activities.
"Replace the tubes immediately so that the created opening does not close." The mother of a child who had a myringotomy with insertion of tympanostomy tubes calls the nurse and tells the nurse that the "tubes" fell out. The nurse should make which response to the mother?
"This is not an emergency. I will speak to the primary health care provider and call you right back."
Rotavirus The nurse in the pediatric clinic is planning care for a 2-month-old client who has been brought to the clinic for a well-child exam and 2-month immunizations. The infant is afebrile and does not exhibit signs of a respiratory infection. The mother tells the nurse that the child developed a rash and difficulty breathing after the mother applied Neosporin ointment to a scrape on the baby's leg. The nurse knows which vaccines are safe to administer to the child? Select all that apply.
Rotavirus Hepatitis B Pneumococcal Diphtheria, tetanus, pertussis Haemophilus influenzae type b
SIDS usually occurs during sleep and is more common in girls. A nursing student is asked to discuss sudden infant death syndrome (SIDS) at the clinical conference being held at the end of the clinical day. The student plans to include which information in the discussion during the conference?
SIDS usually occurs during sleep and is more common in premature infants.
Drag the text in the left column to the correct order in the right column. The nurse is attempting to ensure the parent is able to safely administer the prescribed ear drops to the 2-year-old client at home. The parent demonstrates understanding of the teaching by listing the steps of the process in which priority order? Arrange the actions in the order that they should be performed. All options must be used.
1. Warm the bottle of ear drops by rolling it in the palms of the hands to help decrease discomfort. Have the child lie on his or her back with the affected ear facing up. 2 Have the child lie on his or her back with the affected ear facing up. Straighten the ear canal by pulling the pinna of the affected ear down and back. 3 Straighten the ear canal by pulling the pinna of the affected ear down and back. Slowly instill the number of drops prescribed by the primary health care provider into the ear. 4Slowly instill the number of drops prescribed by the primary health care provider into the ear. Massage the area anterior to the ear to facilitate entry of the drops. 5Massage the area anterior to the ear to facilitate entry of the drops. Keep the child in the same position for 2 to 3 minutes. 6Keep the child in the same position for 2 to 3 minutes.
Document the findings. The nurse is checking the capillary refill of a child with a cast applied to the left arm. The nurse compresses the nail bed of a finger, and it returns to its original color in 2 seconds. Which action should be taken by the nurse?
Document the findings.
Monitor vital signs. Following a tonsillectomy, which of the primary health care provider's prescriptions should the nurse question?
Allow ice cream when awake.
Hip joint laxity The nurse is reviewing the health care record of an infant suspected of having unilateral hip dysplasia. Which finding should the nurse expect to note documented in the infant's record regarding this condition?
Hip joint laxity
A flat position An infant returns to the nursing unit after the surgical repair of a cleft lip located on the right side of the lip. Which is the best position to place this infant at this time?
Initiate an intravenous line. Maintain nothing-by-mouth status. Administer intravenous antibiotics. Administer preoperative medications.
Requires frequent pin care A child with a fractured femur is placed in Buck's skin traction, and the nurse is planning care for the client. Which information about this type of traction is correct?
Is a type of skin traction that pulls the hip and leg into extension
It is a complete small intestinal obstruction. A mother of an infant diagnosed with Hirschsprung's disease asks the nurse about the disorder. The nurse plans to base the response on which information?
It is a congenital aganglionosis or megacolon.
725 mL The nurse is planning care for a hospitalized child with syndrome of inappropriate antidiuretic hormone (SIADH). The primary health care provider has prescribed that the 24-hour fluid maintenance for the child weighing 12 kg be at ¾ of the maintenance. Using the formula shown (refer to figure), which volume of fluid should the nurse plan as the 24-hour maintenance for this child?
825 mL
A 30-degree angle when supine The nurse provides instructions to the parents of an infant with gastroesophageal reflux (GER) regarding proper positioning to manage reflux. The nurse should tell the parents that the infant should be maintained in which position?
A 60-degree angle when supine
A lack of appetite The nurse is caring for a child with a fracture who is placed in skeletal traction. The nurse monitors for the most serious complication associated with this type of traction by checking for which?
An elevated temperature
Elevated creatinine level A 12-year-old child is seen in the clinic, and a diagnosis of Hodgkin's disease is suspected. Several diagnostic studies are performed to determine the presence of this disease. When evaluating the diagnostic results, the nurse should expect to note which evidence if this child has Hodgkin's disease?
The presence of Reed-Sternberg cells
Turn the child to the side. After a tonsillectomy, the child begins to vomit bright red blood. Which is the initial nursing action?
Turn the child to the side.
Pain A child is admitted to the hospital with sickle cell crisis. The nurse checks this child for which frequent symptom of the disorder?
Pain
"I can remove the harness to bathe my infant." The nurse provides instructions to the parents of an infant with hip dysplasia regarding care of the Pavlik harness. Which statement, if made by one of the parents, indicates an understanding of the use of the harness?
"I can remove the harness to bathe my infant."
Diarrhea A 3-year-old child is seen in the health care clinic, and a diagnosis of encopresis is made. The nurse reviews the record, expecting to note which sign as evidence of this disorder?
Evidence of soiled clothing
"I will encourage my child to avoid standing for too long." When reinforcing instructions to the caregiver of a child about cast care, the nurse anticipates the need for further teaching when the caregiver makes which statement?
"I will allow my child to put cotton balls inside the cast to relieve pressure."
"I need to use a water-soluble lubricant." The nurse reinforces home care instructions to the parents of an infant following surgical intervention for imperforate anus and tells the parents about the procedure for anal dilation. Which statement by the parents indicates the need for further teaching?
"I will insert a glycerin suppository before the dilation."
Use aspirin for pain relief. The nurse is reinforcing home care instructions to the mother of an infant who has just been found to have hemophilia. The nurse should instruct the mother to do which?
Pad crib rails and table corners.
"Has your child had any diarrhea?" The nurse is collecting data on a child recently diagnosed with glomerulonephritis. Which question to the mother should elicit information about the cause of this disease?
"Did your child recently complain of a sore throat?"
"Feed the infant in an upright position." The nurse reinforces instructions to parents regarding the methods that will decrease the risk of recurrent otitis media in infants. Which should the nurse include in the instructions?
"Feed the infant in an upright position."
"Has the child been vomiting?" The nurse is collecting data on a child with a diagnosis of rheumatic fever. Which question should the nurse initially ask the mother of the child?
"Has the child complained of a sore throat within the past few months?"
"I can give my child rice." The nurse is reinforcing dietary instructions to the mother of a child with celiac disease. Which statement by the mother indicates a need for further teaching?
"I am so pleased that I won't have to eliminate oatmeal from my child's diet."
Hold the next dose of insulin. The mother of a 6-year-old child who has type 1 diabetes mellitus calls a clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the child's urine and it was positive for ketones. The nurse should instruct the mother to take which action?
Encourage the child to drink liquids.
Sibling rivalry will cause regression to occur. A 1-year-old child with hypospadias is scheduled for surgery to correct this condition. The nurse is asked to assist in preparing a plan of care for this child. During this developmental time period, which factor should the nurse take into account?
Fears of separation and mutilation are present.
Initiating seizure precautions To ensure a safe environment for a child admitted to the hospital for a craniotomy to remove a brain tumor, the nurse should include which in the plan of care?
Initiating seizure precautions
The child's hands A school nurse is preparing a physical education plan for a child with Down syndrome. Before preparing the plan, the nurse obtains which copy of an x-ray report?
The child's cervical spine
"I will not mix the medication with food." The nurse provides homecare instructions to the parents of a child with heart failure regarding the procedure for the administration of digoxin. Which statement by a parent indicates the need for further teaching?
"If my child vomits after medication administration, I will repeat the dose."
Denies shortness of breath or difficulty breathing The nurse is developing goals for a school-age child with a knowledge deficit related to the use of inhalers and peak flow meters. The nurse identifies which goal as appropriate for this child?
Expresses feelings of mastery and competence with breathing devices
Assist to administer morphine sulfate The nurse was caring for an infant who had come to the nursing unit for observation and treatment of tetralogy of Fallot. The child suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. The nurse should perform which action first?
Administer 100% oxygen by face mask.
A recent cold The nurse obtains a health history from a mother of a 15-month-old child before administering a measles, mumps, and rubella (MMR) vaccine. Which is essential information to obtain before the administration of this vaccine?
Allergy to eggs
Macular rash on the trunk and scalp A child is diagnosed with chicken pox. The nurse collects data regarding the child. Which finding is characteristic of chicken pox?
Macular rash on the trunk and scalp
Administer an antiemetic. A child who has undergone spinal fusion for scoliosis complains of abdominal discomfort and begins to have episodes of vomiting. On further assessment, the nurse notes abdominal distention. On the basis of these findings, the nurse should take which action?
Notify the registered nurse.
One sugar cube The nurse determines that a child with type 1 diabetes mellitus is having a hypoglycemic reaction. Which supplement should the nurse give the child to treat the reaction?
½ cup of fruit juice
"The child may be allergic to antibiotics." A hospitalized 2-year-old child with croup is receiving corticosteroid therapy. The mother asks the nurse why the primary health care provider did not prescribe antibiotics. The nurse makes which response to the mother?
"Antibiotics are not indicated unless a bacterial infection is present."
Headache The nurse is assigned to care for a child who is suspected of having glomerulonephritis. The nurse reviews the child's record and notes that which findings are associated with the diagnosis of glomerulonephritis? Select all that apply.
Headache Red-brown urine Periorbital edema
Monitor vital signs once a shift. A 4-year-old child with acute lymphocytic leukemia has been admitted to the hospital in relapse. The priority concern is infection due to immunosuppression. Which interventions should the nurse include in the plan of care?
Perform oral hygiene four times a day.
Assess hearing loss. A child is diagnosed with Reye's syndrome. The nurse assists with developing a nursing care plan for the child and should include which intervention in the plan?
Provide a quiet atmosphere with dimmed lighting.
The child is crying and irritable. A 1-year-old child is seen in the primary health care provider's office with complaints of an elevated temperature that began the previous evening. When gathering subjective data from the mother, the nurse notices that which sign/symptom would most likely indicate the child has acute otitis media?
The mother states the child had purulent discharge from the ear last night.
"I'll check his temperature." The nurse is reinforcing discharge instructions to the parent of a 2-year-old child who has had an orchiopexy to correct cryptorchidism. Which statement by the parent indicates a need for further teaching?
"I'll let him decide when to return to his play activities."
"Breastfeeding must be stopped immediately." A 5-week-old infant is brought to the well-baby clinic by the mother because the mother has noted white patches in the infant's mouth. Following examination, the infant is diagnosed with oral candidiasis (thrush). Nystatin oral suspension is prescribed. The mother is concerned because she is breastfeeding the infant and asks the nurse if breastfeeding can be continued. Which response is appropriate?
"You should bottle-feed the infant for 1 week and then resume breastfeeding."
Scarring is less severe in a child than in an adult. The nurse caring for a child who sustained a burn injury plans care based on which pediatric considerations associated with this injury? Select all that apply.
A delay in growth may occur after a burn injury. An immature immune system presents an increased risk of infection for infants and young children. Infants and young children are at increased risk for protein and calorie deficiency because they have smaller muscle mass and less body fat than adults.
Obtain a blood glucose reading. The nurse is caring for a hospitalized child newly diagnosed with type 1 diabetes mellitus. At 11:00 am, the child suddenly complains of weakness, headache, and blurred vision. How should the nurse respond?
Obtain a blood glucose reading. Obtain a blood glucose reading.
Peripheral hypoxia A 5-year-old child is admitted to the hospital for heart surgery to repair tetralogy of Fallot. The nurse notes that the child has clubbed fingers, and the nurse knows that this symptom is likely a result of which condition?
Preventing infection at the surgical site
Oral antibiotics A mother arrives at the clinic with her child. The mother tells the nurse that the child has had a fever and a cough for the past 2 days, and this morning the child began to wheeze. Viral pneumonia is diagnosed. Which component of the treatment plan should the nurse anticipate?
Supportive treatment
Hematuria The nurse collects a urine specimen preoperatively from a child with epispadias who is scheduled for surgical repair. The nurse reviews the child's record for the laboratory results of the urine test and would most likely expect to note which finding?
Bacteriuria
Fats and vitamin A The nurse reinforces instructions to the mother about dietary measures for a 5-year-old child with lactose intolerance. The nurse should tell the mother that which supplement will be required as a result of the need to avoid lactose in the diet?
Calcium and vitamin D
Diphtheria, tetanus, acellular pertussis (DTaP), Measles, mumps, rubella (MMR), inactivated poliovirus vaccine (IPV) A mother brings her 4-month-old infant to the well-baby clinic for immunizations. Which immunizations should be administered to this infant?
DTaP, Hib, IPV, pneumococcal vaccine (PCV)
Oliguria The nurse is checking a child for dehydration and documents that the child is moderately dehydrated. Which symptoms should be noted in determining this finding? Select all that apply.
Oliguria Slightly sunken fontanels Very dry, mucous membranes
Provide adequate nutrition. The nurse is planning care for a child with hemolytic-uremic syndrome (HUS). The child has been anuric and will be receiving peritoneal dialysis treatment. The nurse should plan to include which interventions in the care of the child? Select all that apply.
Provide adequate nutrition. Restrict fluids, as prescribed. Institute measures to prevent infection. Administer blood products to treat severe anemia. Anticipate the child will have central nervous system involvement.
Morning pulse of 76 beats per minute An adolescent client with type 1 diabetes is experiencing high glucose levels upon awakening in the morning. After reviewing the client's chart, the nurse determines that the elevated glucose level in the morning is due to the Somogyi effect. Which finding should lead the nurse to this conclusion? Refer to chart.
Glucose level at 2 am of 65 mg/dL
Keeping the weights hanging freely The nurse is assigned to care for a child who is in skeletal traction. The nurse needs to avoid which action when caring for the child?
Placing the bed linens on the traction ropes
Administer regular insulin. Which interventions should the nurse implement for a child older than 2 years of age with type 1 diabetes mellitus who has a blood glucose level of 60 mg/dL? Select all that apply.
Give the child a teaspoon of honey. Prepare to administer glucagon subcutaneously if unconsciousness occurs.
Vigorously massage bony prominences every 4 hours. The nurse is caring for a pediatric client in skin traction. To prevent skin breakdown, which nursing intervention for this child is best?
Stimulate circulation with gentle massage over pressure areas.
Tuck pant legs into socks. The nurse is reinforcing instructions regarding the prevention of Lyme disease to a group of teenagers going on a hike in a wooded area. Which points should the nurse include in the session? Select all that apply.
Tuck pant legs into socks. Wear closed shoes when hiking. Apply insect repellent containing DEET. Cover the ground with a blanket when sitting.
Urinary output is increased. The nurse is collecting data from a child with a diagnosis of diabetes insipidus. Which clinical finding is consistent with this diagnosis?
Urinary output is increased.
