Nclex peds practice test
A nurse is reviewing a health care provider's prescription for a child who was just admitted to the hospital with a diagnosis of Kawasaki disease. Which prescription should the nurse anticipate being part of the treatment plan?
Immune globulin
A nurse reinforces instructions to the mother of a child with croup about the measures to take if an acute spasmodic episode occurs. Which statement by the mother indicates the need for further instruction?
"I will place a steam vaporizer in my child's room."
A nurse is preparing a 2-year-old child with suspected nephrotic syndrome for a renal biopsy to confirm the diagnosis. The mother asks the nurse, "Will my child ever look thin again?" The nurse appropriately responds by saying:
"In most cases, medication and diet will control fluid retention."
A cooling blanket is prescribed for a child with a fever. The nurse prepares to use the cooling blanket and avoids which of the following?
Keeping the child uncovered to assist in reducing the fever
A nurse is reviewing the record of a child admitted to the hospital with nephrotic syndrome. Which finding would the nurse expect to note documented in the record?
Proteinuria
A 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 finding is associated with the diagnosis of glomerulonephritis?
Red-brown urine
A nurse is caring for a 2-year-old child diagnosed with croup. The nurse collects data on the child, knowing that which of the following are characteristic of this illness? Select all that apply.
*The cough is harsh and metallic. *Inspiratory stridor may be present. *Symptoms usually worsen at night and are better during the day. *It is usually preceded by several days of upper respiratory infection symptoms.
A nursing instructor asks a nursing student about the cause of hemophilia. The student correctly responds by telling the instructor that:
Hemophilia A results from deficiency of factor VIII.
A nurse is assisting with data collection from an infant who has been diagnosed with hydrocephalus. If the infant's level of consciousness diminishes, a priority intervention is:
Palpating the anterior fontanel
A nurse receives a call from the mother whose child has a foreign body in the eye. The object is clearly visible and not embedded. When the mother asks for the most effective way to get it out, the nurse responds:
Touch the object gently with a cotton swab, and lift it out.
A health care provider prescribes intravenous potassium for a child with hypertonic dehydration. The nurse assigned to assist in caring for the child would check which highest-priority item before administration of the potassium?
Urine output
A nurse is reviewing the health care record of an infant suspected of having unilateral hip dysplasia. Which assessment finding would the nurse expect to note documented in the infant's record regarding this condition?
Asymmetry of the gluteal skin folds when the infant is placed prone and the legs are extended against the examining table
A school-age child with type 1 diabetes mellitus has soccer practice three afternoons a week. The nurse reinforces instructions regarding how to prevent hypoglycemia during practice. The nurse tells the child to:
Drink a half a cup of orange juice before soccer practice.
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 of the following interventions would the nurse include in the plan of care?
Perform oral hygiene four times a day.
A nurse is assisting in developing a plan of care for a 10-year-old child diagnosed with acute glomerulonephritis. Following review of the plan of care, the nurse determines that which of the following is the priority for the child?
Promoting bedrest
A nurse provides home care instructions to a client with sickle cell anemia. Which statement by the client indicates a need for further instruction?
"When I'm feeling better, I'm returning to the soccer team."
A nurse reviews the results of a Mantoux test performed on a 3-year-old child. The results indicate an area of induration that measures 10 mm. The nurse would interpret these results as:
Positive
A 9-year-old child is diagnosed with chlamydial conjunctivitis. The nurse consults with the primary health care provider regarding necessary follow-up because this infection can be associated with:
Possible sexual abuse
A hospitalized 2-year-old child with croup is receiving corticosteroid therapy. The mother asks the nurse why the 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."
A child is scheduled for a tonsillectomy in the day-stay surgical unit. On the day following surgery, the mother calls the surgical unit and expresses concern because the child has a very bad mouth odor. The nurse makes which response to the mother?
"Bad mouth odor is normal and may be relieved by drinking more liquids."
A nurse determines that an adolescent client with diabetes mellitus needs further information about glycosylated hemoglobin levels and their purpose if the client made which statement when told that a level will be drawn?
"I already had a complete blood cell [CBC] count drawn an hour ago, so this test is not necessary."
A 4-year-old child sustains a fall at home and is brought to the emergency department by the mother. After an x-ray, it is determined that the child has a fractured arm, and a plaster cast is applied. The nurse provides instructions to the mother regarding cast care for the child. Which statement by the mother indicates the need for further instructions?
"I can use lotion or powder around the cast edges to relieve itching."
A nurse provides information to the mother of a 2-week-old infant who was diagnosed with clubfoot at the time of birth. Which statement by the mother indicates the need for further instruction regarding this disorder?
"I need to bring my child back to the clinic in 1 month for a new cast."
A nurse provides home care instructions to the mother of a child recovering from Reye's syndrome. Which statement by the mother indicates a need for further instruction?
"I need to give frequent, small, nutritious meals if my child starts to vomit."
A nursing student is asked to discuss juvenile idiopathic arthritis (JIA) at a clinical conference scheduled for the end of the clinical day. Which statement by the nursing student indicates the need to further research this disorder?
"This disease is twice as likely to occur in boys rather than girls."
A nurse is providing instructions to a child with cystic fibrosis regarding how to perform the "huff" maneuver. The child asks the nurse about the purpose of this type of breathing. The appropriate nursing response is which of the following?
"This type of breathing is used to mobilize secretions so that they can be easily coughed out."
Which statement should the nurse include when providing safety instructions to the parents of an infant with a diagnosis of hydrocephalus?
"When picking up your infant, support the infant's neck and head with the open palm of your hand."
A child with sickle cell anemia is being discharged after treatment for a crisis. Which instructions should the nurse provide to prevent another crisis from occurring? Select all that apply.
*Drink plenty of fluids. *Wash hands before meals and after playing. *Report a sore throat immediately.
A nurse is caring for an infant with a diagnosis of Hirschsprung's disease. The nurse should check for which clinical findings that are consistent with Hirschsprung's disease? Select all that apply.
*Fever *Constipation *Failure to thrive *Abdominal distention *Explosive, watery diarrhea
A 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:
An elevated temperature
A mother of a child with cystic fibrosis asks the nurse when the postural drainage should be performed. The mother states that the child eats meals at 8:00 AM, 12 noon, and at 6:00 PM The nurse tells the mother that the postural drainage should be performed at:
10:00 AM, 2:00 PM and 8:00 PM
A mother of a 5-year-old child brings the child to the emergency department and tells the nurse that the child fell. A fracture is suspected and an x-ray is taken. The results indicate that the child has a comminuted fracture of the right humerus. The mother asks the nurse to describe this type of fracture, and the nurse draws a picture for the mother. Which picture identifies this type of a fracture? *Refer to figure*
2
The parents of a newborn have been told that their child was born with bladder exstrophy, and the parents ask the nurse about this condition. The nurse bases the response on knowledge that this condition is:
An extrusion of the urinary bladder to the outside of the body through a defect in the lower abdominal wall
A nurse is monitoring a child with a cast on the forearm for signs of compartment syndrome. The nurse understands that which data collection technique is unlikely to provide information about this complication?
Checking the child's ability to perform range of motion to the shoulder area of the affected extremity
A nurse in a newborn nursery is told that a newborn with spina bifida (myelomeningocele type) will be transported from the delivery room. The nurse is asked to prepare for the arrival of the newborn. The nurse places which of the following priority items at the newborn's bedside?
A bottle of sterile normal saline
A nurse obtains a health history from a mother of a 15-month-old child before administering a measles, mumps, and rubella (MMR) vaccine. Which of the following is essential information to obtain before the administration of this vaccine?
Allergy to eggs
Following tonsillectomy, which of the health care provider's prescriptions would the nurse question?
Allow ice cream when awake.
A nurse employed in an emergency department is instructed to monitor a child diagnosed with epiglottitis. The nurse notes that the child is leaning forward with the chin thrust out. The nurse interprets this finding as indicating:
An airway obstruction
A lethargic, pale child is brought to the health care provider's office with symptoms of periorbital edema and reduced quantity of urine output. The urine is cloudy and smoky in color. The nurse asks the mother if the child has had any recent infections, to which the mother responds that the child had a very sore throat a few weeks ago. The health care provider suspects that the child might have acute poststreptococcal glomerulonephritis. Which of the following laboratory tests would rule out a past streptococcal infection in the child?
Antistreptolysin titer
A nurse prepares to administer a pancreatic enzyme powder to the child with cystic fibrosis (CF). Which of the following food items will the nurse mix with the medication?
Applesauce
A newborn is transferred to the neonatal intensive care unit with an admitting diagnosis of esophageal atresia accompanied by a distal tracheoesophageal fistula (TEF). When assisting to care for the newborn, the priority concern would be:
Aspiration
An emergency department nurse is gathering initial data on a child suspected of epiglottitis. The nurse's priority would be to:
Assess for a patent airway.
A sweat test is performed on a child with a suspected diagnosis of cystic fibrosis (CF). Which test result is suggestive of cystic fibrosis and will require further assessment and investigation?
Chloride level of 40 mEq/L
A nurse is providing discharge instructions to the mother of a child who had a myringotomy with insertion of tympanostomy tubes. The nurse instructs the mother that if the tubes fall out, she should:
Contact the health care provider.
A mother brings her 15-month-old child to the health care provider's office with complaints that the child has suddenly developed a bright red rash on her cheeks. She has no other symptoms and has been playing and eating as usual. Based on the appearance of the child, the nurse might suspect that the child has:
Fifth disease
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.
A mother of a child who underwent a myringotomy with insertion of tympanostomy tubes calls the nurse and reports that the child is complaining of discomfort. The nurse tells the mother to:
Give the child acetaminophen (Tylenol) for the discomfort.
A child suspected of sickle cell disease is seen in the clinic, and laboratory studies are performed. The nurse reviews the results of the laboratory studies and expects to note which of the following that is a characteristic of this disease?
Increased reticulocyte count
A nurse is preparing to care for a child who received an allogenic bone marrow transplant (BMT). The nurse understands that which of the following is the priority concern?
Infection
A nursing student is asked to discuss the topic of clubfoot at a clinical conference. The student plans to tell the group that clubfoot:
Is a congenital anomaly
Which of the following represents a primary characteristic of autism?
Lack of social interaction and awareness
A child with croup is placed in a cool-mist tent. The mother becomes concerned because the child is frightened, consistently crying, and tries to climb out of the tent. The appropriate nursing action would be to:
Let the mother hold the child and direct a cool mist over the child's face
A 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 of the following?
Level of consciousness (LOC)
A nurse is reviewing the laboratory results of an infant suspected of having hypertrophic pyloric stenosis. Which of the following would the nurse expect to note in this infant?
Metabolic alkalosis
A licensed practical nurse (LPN) is bathing a neonate and notices small dark tufts of fine hair on the neonate's lower back. The LPN should take which best action?
Notify the registered nurse of the finding.
A nurse is monitoring an infant for signs of increased intracranial pressure (ICP) and notes that the anterior fontanel bulges when the infant is sleeping. Based on this finding, which of the following is the priority nursing action?
Notify the registered nurse.
A nurse has provided dietary instructions to the mother of a child with celiac disease. The nurse determines that further instructions are needed if the mother states that she will include which of the following in the child's nutritional plan?
Oatmeal
An infant returns to the nursing unit after the surgical repair of a cleft lip located on the right side of the lip. The best position in which to place this infant at this time is:
On his or her left side
A child is admitted to the hospital with sickle cell crisis. The nurse checks this child for which frequent symptom of the disorder?
Pain
A nurse is assigned to care for a child who is in skeletal traction. The nurse avoids which of the following when caring for the child?
Placing the bed linens on the traction ropes
The child with cryptorchidism is being discharged after orchiopexy, which was performed on an outpatient basis. The nurse informs the parents about which priority care measure?
Preventing infection at the surgical site
The nurse assists with preparing a nursing care plan for a child who has Reye's syndrome. Which of the following is the priority nursing intervention?
Providing a quiet atmosphere with dimmed lights
A nurse is monitoring a child following a tonsillectomy. Which finding may indicate that the child is bleeding?
Restlessness
A nurse is assisting in admitting to the hospital a 4-month-old infant with a diagnosis of vomiting and dehydration. The nurse assists in developing a plan of care for the infant and suggests including in the plan to position the infant in a(n):
Side-lying position
A nurse reviews the plan of care for a child with Reye's syndrome. The nurse prioritizes the nursing interventions included in the plan and prepares to monitor for:
Signs of increased intracranial pressure
A licensed practical nurse is providing care for a child with hydrocephalus who has had a ventriculoperitoneal shunt revision. Which data collection finding should be reported to the registered nurse immediately?
Temperature 100.9° F
A nurse is providing home care instructions to the mother of a child with bacterial conjunctivitis. The nurse should tell the mother:
That the child's towels and washcloths should not be used by other members of the household
A child with a tracheal obstruction is brought to the emergency department by emergency medical services. The child aspirated a grape, and the foreign body was removed by direct laryngoscopy. Following the procedure, the nurse plans to inform the mother of the child that:
The child will need to be hospitalized for observation.
A nurse provides 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.
A 2-year-old child is diagnosed with constipation. Which of the following describes a characteristic of this disorder?
The infrequent and difficult passage of dry stools
A 1-year-old child is seen in the 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 of the following would most likely indicate the child has acute otitis media?
The mother states the child had purulent discharge from the ear last night.
An infant is suspected to be human immunodeficiency virus (HIV) positive, and the nurse provides information to the parents about the care of their infant. Which of the following indicates to the nurse that the parents need further information about the care of their HIV-positive infant?
The parents plan to use rice cereal to help with watery stools when they occur.
A nurse is providing information to the family of a child about a synthetic cast that has been applied to the child for the treatment of a clubfoot. Which information should the nurse provide to the mother?
The synthetic cast allows for greater mobility than a plaster cast.
An infant returns to the nursing unit following surgery for an esophageal atresia with tracheoesophageal fistula (TEF). The infant is receiving intravenous (IV) fluids, and a gastrostomy tube is in place. The nurse who is assisting in caring for the infant will ensure that the gastrostomy tube is:
elevated
A nurse is reinforcing instructions to the mother of an 8-year-old child who had a tonsillectomy. The mother tells the nurse that the child loves tacos and asks when the child can safely eat one. The nurse makes which response to the mother?
in 3 weeks
A nurse is caring for a 1-year-old child following a cleft palate repair. Which solution should the nurse use after feedings to cleanse the child's mouth?
water
A nurse provides 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 instructions?
"I need to be sure my child uses soft tissues to blow his nose."
Griseofulvin (Gris-PEG) is prescribed for a child with tinea capitis. The nurse provides instructions to the family regarding administration of the medication. Which statement by the mother indicates a need for further instructions?
"I need to administer the medication 2 hours before meals."
A client has been prescribed valproic acid (Depakene) for the treatment of generalized seizures, and the nurse teaches the child about the potential side effects of the medication. Which statement by the client would indicate that further teaching is required?
"I am so glad that I won't lose any of my hair. I was worried what my friends would think."
A nurse reinforces instructions to the mother of a child who has been hospitalized with croup. Which of the following statements, if made by the mother, would indicate the need for further instruction?
"I will give my child cough syrup if a cough develops."
A nurse provides 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 instructions?
"I will insert a glycerin suppository before the dilation."
A nurse has provided instructions to the mother of a child who has been diagnosed with bacterial conjunctivitis. Which of the following, if stated by the mother, would indicate the need for further instructions?
"It is OK to share towels and washcloths."
A nurse is providing 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 instruction?
"The full range-of-motion (ROM) exercises must be performed every day, even during the exacerbations."
Antibiotics are prescribed for a child following a myringotomy with insertion of tympanostomy tubes, and the nurse provides instructions to the parents regarding the administration of the antibiotics. Which statement, if made by a parent, would indicate that the instructions were understood?Antibiotics are prescribed for a child following a myringotomy with insertion of tympanostomy tubes, and the nurse provides instructions to the parents regarding the administration of the antibiotics. Which statement, if made by a parent, would indicate that the instructions were understood?
"We will administer the antibiotics until they are gone."
A nurse is collecting data from a child suspected of having juvenile idiopathic arthritis (JIA). Which findings would the nurse expect to note if JIA were present? Select all that apply.
*Malaise, fatigue, and lethargy *Painful, stiff, and swollen joints *Limited range of motion of the joints *History of late afternoon temperature, with temperature spiking up to 105° F
A 1-year-old child is admitted to the hospital for control of tonic-clonic seizures. The nurse would do which of the following in order to protect the child from injury? Select all that apply.
*Remove toys that have bright, blinking lights on them. *Keep side rails and other hard objects padded. *Turn the client to the side during a seizure.
A nurse is developing a plan of care for a child who is at risk for seizures. Which interventions apply if the child has a seizure? Select all that apply.
*Time the seizure *Stay with the child *Move furniture away from the child
A child with diabetes mellitus is brought to the emergency department by her mother, who states that her daughter has been complaining of abdominal pain and has a fruity odor on the breath. Diabetic ketoacidosis (DKA) is diagnosed. The nurse assisting to care for the child checks the intravenous (IV) and medication supply area for which of the following?
0.9% normal saline IV infusion
A nurse is instructing the mother of a child with cystic fibrosis (CF) about the appropriate dietary measures. Which of the following meals best illustrates the most appropriate diet for a client with cystic fibrosis?
A piece of fried chicken and a loaded baked potato
A nurse is preparing to feed a 1-year-old hospitalized child. The nurse prepares the amount of formula to be given to this child, knowing that generally a 1-year-old consumes approximately:
175 mL per feeding
A nurse is monitoring the laboratory values of a child with leukemia who is receiving chemotherapy. The nurse prepares to implement bleeding precautions if the child becomes thrombocytopenic and the platelet count is less than:
20,000/mm3
A mother of a child with cystic fibrosis asks the clinic nurse about the disease. The nurse tells the mother that it is:
A chronic multisystem disorder affecting the exocrine glands
A 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 of the following items will the nurse place at the bedside in preparation for the child's return from surgery?
A cooling blanket
A licensed practical nurse (LPN) is assigned to assist in caring for a hospitalized child who is receiving a continuous infusion of intravenous (IV) potassium for the treatment of dehydration. The LPN monitors the child closely and notifies the registered nurse if which of the following is noted?
A decrease in urine output to 0.5 mL/kg/hr
A nurse is assisting in preparing a plan of care for a child who will be returning from surgery following the application of a hip spica cast. Which of the following would be the priority in the plan of care for this child on return from the procedure?
Check circulation in the feet.
A nurse is preparing to perform a neurovascular check for tissue perfusion in the child with an arm cast. Which of the following is the priority when performing this procedure?
Checking the peripheral pulse in the affected arm
A nurse is caring for a child with a suspected diagnosis of rheumatic fever (RF). The nurse reviews the laboratory results. Which laboratory study would assist in confirming the diagnosis of RF?
Antistreptolysin O titer
A nursing instructor asks a nursing student about the use of bacillus Calmette-Guerin vaccine (BCG). The nursing student responds correctly, knowing that the BCG vaccine is used for:
Asymptomatic human immunodeficiency virus (HIV)-infected children who are at increased risk for developing TB
An 18-month-old child is being discharged after surgical repair of hypospadias. Which postoperative nursing care measure should the nurse stress to the parents as they prepare to take this child home?
Avoid tub baths until the stent has been removed.
Which of the following assessment findings may indicate that a child had a tonic-clonic seizure during the night?
Blood on the pillow
A child is admitted to the hospital, and a diagnosis of bacterial meningitis is suspected. A lumbar puncture is performed, and the results reveal cloudy cerebrospinal fluid (CSF) with high protein and low glucose levels. The nurse determines that these results are indicative of:
Confirmation of the diagnosis
A nurse assists with admitting a child with a diagnosis of acute-stage Kawasaki disease. When obtaining the child's medical history, which clinical manifestation is likely to be reported?
Conjunctival hyperemia
A nurse caring for a child with nephrotic syndrome reviews the medication record. The nurse notes that prazosin hydrochloride (Minipress) is prescribed for the child. The nurse determines that this medication has been prescribed to:
Control hypertension.
A nurse is assisting in developing a plan of care for a diagnosed with acute glomerulonephritis. The nurse includes which intervention in the plan of care?
Encourage limited activity and provide safety measures.
A mother of a 6-year-old child with type 1 diabetes mellitus calls the clinic nurse and tells the nurse that the child has been sick. The mother reports that she checked the child's urine and it showed positive ketones. Which of the following would the nurse instruct the mother to do?
Encourage the child to drink liquids.
A nurse is assisting in preparing a plan of care for a 4-year-old child hospitalized with nephrotic syndrome. Which dietary intervention is most appropriate for this child?
Encourage the child to eat in the playroom.
A nurse reviews the record of a child who was just seen by a health care provider (HCP). The HCP has documented a diagnosis of suspected aortic stenosis. Which clinical manifestation that is specifically found in children with this disorder should the nurse anticipate?
Exercise intolerance
A mother of a 3-year-old child tells the nurse that the child has been continuously scratching the skin and has developed a rash. On data collection, which finding indicates that the child may have scabies?
Fine, grayish-red lines
When checking a child's trochlear nerve function, the nurse would perform which data collection technique?
Have the child look down and in.
A nurse is monitoring a 7-year-old child who sustained a head injury in a motor vehicle accident for signs of increased intracranial pressure (ICP). The nurse assesses the child frequently for which early sign of increased ICP?
Nausea
A nurse is caring for a child following surgical removal of a brain tumor. The nurse is monitoring the child and notes that the pulse rate has increased and the blood pressure has dropped significantly. Bloody drainage also is noted on the posterior dressing. The initial nursing action is to:
Notify the registered nurse (RN).
A nurse assigned to care for a child with mumps is monitoring the child for the signs and symptoms associated with the common complication of mumps. The nurse monitors for which of the following that is indicative of this common complication?
Nuchal rigidity
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. The nurse's initial action would be to:
Obtain a complete history of the child's feeding habits.
A nurse is checking a child for dehydration and documents that the child is moderately dehydrated. Which of the following symptoms would be noted in determining this finding?
Oliguria
A nurse is providing home care instructions to the mother of an infant who has just been found to have hemophilia. The nurse tells the mother to:
Pad crib rails and table corners.
A nurse is assisting a health care provider with an assessment of a child with a diagnosis of suspected appendicitis. In assessing the intensity and progression of the pain, the health care provider palpates the child at McBurney's point. The nurse understands that McBurney's point is located midway between the:
Right anterior superior iliac crest and the umbilicus
A nurse is reinforcing information to parents regarding the signs of meningitis. The nurse informs the parents that the primary signs of meningitis include:
Severe headache and neck stiffness
A nurse assists in preparing a plan of care for the infant with bladder exstrophy. The nurse identifies which of the following immediate problems as the priority for the infant?
Skin disruption
Following a cleft lip repair, the nurse provides instructions to the parents regarding cleaning of the lip repair site. Which of the following solutions would the nurse use in demonstrating this procedure to the parents?
Sterile water
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 of the following would the nurse anticipate to be a component of the treatment plan?
Supportive treatment
A child is seen in the health care clinic and received an immunization of DPT (diphtheria, pertussis, tetanus vaccine). One hour later, the mother calls the clinic and tells the nurse that the injection site is painful and red. Which of the following instructions would the nurse provide to the mother?
To apply cold compresses for 24 hours following the injection
A 10-year-old child with asthma is treated for acute exacerbation. Which finding would indicate that the condition is worsening?
Decreased wheezing
A 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 of the following actions would the nurse take?
Document the findings.
A 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, knowing that:
Each gram of diaper weight is equivalent to 1 mL of urine.
A diagnostic workup is performed on a 1-year-old child suspected of a diagnosis of neuroblastoma. Which finding specifically associated with this type of tumor should the nurse expect to find documented in the child's record?
Elevated vanillylmandelic acid (VMA) levels in the urine
A nurse who is caring for a child with aplastic anemia reviews the laboratory results and notes a white blood cell (WBC) count of 6000 cells/ mm3 and a platelet count of 27,000 cells/mm3. Which nursing intervention should be incorporated into the plan of care?
Encourage quiet play activities.
A nursing student is preparing to conduct a clinical conference, and the topic is hepatitis in children. The nursing instructor advises the student to further research the topic if the student plans to include which of the following in the discussion?
Enteric precautions are necessary for HBV but not for HAV.
A 1-year-old child with hypospadias is scheduled for surgery to correct this condition. A nurse is asked to assist in preparing a plan of care for this child and makes suggestions, knowing that this surgery is taking place at a time when:
Fears of separation and mutilation are present
A child with cerebral palsy (CP) is working to achieve maximum potential for locomotion, self-care, and socialization in school. The nurse would work with the child to meet these goals by:
Placing the child on a wheeled scooter board
After a tonsillectomy, which of the following fluid or food items would be appropriate to offer to the child?
Yellow Jell-O
The mother of a child with juvenile idiopathic arthritis calls the nurse because the child is experiencing a painful exacerbation of the disease. The mother asks the nurse if the child should perform range-of-motion (ROM) exercises at this time. The nurse makes which response to the mother?
"Have the child perform simple isometric exercises during this time."
A mother with human immunodeficiency virus (HIV) infection brings her 10-month-old infant to the clinic for a routine checkup. A health care provider has documented that the infant is asymptomatic for HIV infection. After the checkup, the mother tells the nurse that she is so pleased that the infant will not get HIV. Which response by the nurse is appropriate?
"Most children infected with HIV develop symptoms within the first 9 months of life, and some become symptomatic at some point before the age of 3 years."
A child is brought to the emergency department, and a fracture of the left lower arm is suspected. The mother states that the child was rollerblading and attempted to break a fall with an outstretched arm. The child receives diagnostic x-rays, from which it has been determined that a fracture is present. A plaster of Paris cast is applied to the arm, and the nurse provides instructions to the mother regarding cast care at home. Which of the following instructions would the nurse provide to the mother?
"The cast needs to be kept dry because, when wet, it will begin to disintegrate."
A nurse is caring for an infant with a diagnosis of tetralogy of Fallot. The infant suddenly becomes cyanotic and the oxygen saturation reading drops to 60%. Choose the interventions that the nurse should perform. Select all that apply.
*Notify the registered nurse. *Prepare to administer morphine sulfate. *Prepare to administer intravenous fluids. *Prepare to administer 100% oxygen by face mask.
A nurse is preparing to administer digoxin (Lanoxin) to an infant with congestive heart failure (CHF). Before administering the medication, the nurse double-checks the dose, counts the apical heart rate for 1 full minute, and obtains a rate of 88 beats per minute. Based on this finding, which of the following is the appropriate nursing action?
Withhold the medication.
A nurse is monitoring a child with a head injury. On data collection, the nurse notes an abnormal flexion of the upper extremities and an extension of the lower extremities. The nurse documents that the child is experiencing:
Decorticate posturing
A nurse employed in the emergency department is collecting data on a 7-year-old child with a fractured arm. The child is hesitant to answer questions that the nurse is asking and consistently looks at the parents in a fearful manner. The nurse suspects physical abuse and continues with the data collection procedures. Which of the following findings would most likely assist in verifying the suspicion?
Bald spots on the scalp
A nurse is assigned to care for a child admitted to the hospital with a diagnosis of suspected bacterial endocarditis. The nurse prepares the child for which of the following diagnostic tests that will confirm the diagnosis?
Blood cultures
A nurse is caring for a child who sustained a head injury in an automobile accident and is monitoring the child for signs of increased intracranial pressure (ICP). The nurse plans to monitor for the earliest sign of increased ICP by assessing for:
Changes in level of consciousness (LOC)
A nurse has reviewed the health care provider's prescriptions for a child suspected of a diagnosis of neuroblastoma and is preparing to implement diagnostic procedures that will confirm the diagnosis. The nurse prepares to:
Collect a 24-hour urine sample.
A nurse is caring for a child diagnosed with Down syndrome. In describing the disorder to the parents, the nurse bases the explanation on the fact that Down syndrome is a:
Congenital condition that results in moderate to severe retardation and has been linked to an extra chromosome 21 (group G)
A nurse is reviewing the health care provider's prescriptions for a child with rheumatic fever who is suspected of having a viral infection. The nurse notes that acetylsalicylic acid (aspirin) is prescribed for the child. Which of the following nursing actions is appropriate?
Consult with the registered nurse to verify the prescription.
A nurse is reviewing the laboratory results of a child scheduled for tonsillectomy. Which laboratory value would be significant to review?
Platelet count
After a tonsillectomy, the child begins to vomit bright red blood. The initial nursing action would be to:
Turn the child to the side.
A 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.
A nurse is assigned to care for a child with a spica cast. Which action should be avoided when caring for the child?
Using pillows to elevate the head and shoulders
A health care provider has prescribed oxygen as needed for a 10-year-old child with congestive heart failure (CHF). In which situation would the nurse administer the oxygen to the child?
When drawing blood for the measurement of electrolyte levels
A nurse is caring for a hospitalized infant with a diagnosis of bronchiolitis. The nurse positions the infant:
With the head and chest at a 30-degree angle, with the neck slightly extended
A nurse is assigned to care for a child who is scheduled for an appendectomy. Which prescriptions does the nurse anticipate will be prescribed? Select all that apply.
*Initiate an intravenous line. *Maintain nothing-by-mouth status. *Administer intravenous antibiotics. *Administer preoperative medications.
A child is admitted to the pediatric unit with a diagnosis of coarctation of the aorta (COA). The health care provider prescribes that the child's blood pressure be taken every 4 hours in the legs and arms. The nurse would expect the blood pressure in the child's legs and arms to be:
Decreased in the legs and increased in the arms
A 6-year-old child with leukemia is hospitalized and is receiving combination chemotherapy. Laboratory results indicate that the child is neutropenic, and the nurse prepares to implement protective isolation procedures. Which interventions would the nurse initiate? Select all that apply.
*Place the child on a low-bacteria diet. *Change dressings using sterile technique. *Perform meticulous handwashing before caring for the child.
The nurse should implement which of the following in the care of a child who is having a seizure? Select all that apply.
*Time the seizure. *Stay with the child. *Loosen clothing around the child's neck.
A child with leukemia is experiencing nausea related to medication therapy. The nurse, concerned about the child's nutritional status, should offer which of the following during this episode of nausea?
Cool, clear liquids
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 of the following?
It is a congenital aganglionosis or megacolon.
A nurse is assisting in planning discharge instructions to the mother of a child following orchiopexy, which was performed on an outpatient basis. Which of the following is the priority in the plan of care?
Wound care
A health care provider has told the mother of a newborn diagnosed with strabismus that surgery will be necessary to realign the weakened eye muscles. The mother asks the nurse when the surgery might be performed. The nurse responds by telling the mother that surgery will probably be performed:
Before the child is 3 years old
A nurse reinforces instructions to the mother about dietary measures for a 5-year-old child with lactose intolerance. The nurse tells the mother that which of the following supplements will be required as a result of the need to avoid lactose in the diet?
Calcium
A nurse provides instructions regarding the use of permethrin 1% (Nix) to the parents of a child who has been diagnosed with pediculosis capitis (head lice). Which statement by a parent indicates the need for further instruction?
"The medication is applied to the hair after shampooing and left on for 24 hours."
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 of the following in the plan of care?
Initiating seizure precautions
A child is diagnosed with scarlet fever. A nurse collects data regarding the child. Which of the following is a clinical manifestation of scarlet fever?
Pastia's sign
A child with rubeola (measles) is being admitted to the hospital. When preparing for the admission of the child, which precautions should be implemented?
Respiratory
A nurse is assisting in preparing a plan of care for a child who is being admitted to the pediatric unit with a diagnosis of seizures. Which of the following would be a component of the plan of care? Select all that apply.
*Pad the side rails of the bed with blankets. *Maintain the bed in a low position. *Place the child in a side-lying lateral position if a seizure occurs. *Protect the child's head, body, and extremities if a seizure occurs.
Oral iron is prescribed for a child with an iron deficiency anemia, and the nurse provides instructions to the mother regarding the administration of the iron. The nurse instructs the mother to administer the iron:
Between meals
A mother of a 6-year-old-child calls a nurse who lives in the neighborhood and tells the nurse that her child accidentally rubbed waterproof sunscreen in his eyes. The nurse should tell the mother to immediately:
Call the poison control center.
A school nurse is preparing a physical education plan for a child with Down syndrome. Before preparing the plan, the nurse obtains a copy of an x-ray report of the child's:
Cervical spine
After a tonsillectomy, a child is brought to the pediatric unit. The nurse places the child in which appropriate position?
Prone
