NURS 315 exam 3

A nurse is collecting data from a child who is descending stairs by placing both feet on each step and holding on to the railing. The nurse should understand that these actions are developmentally appropriate at which of the following ages? A. 3 years B. 4 years C. 5 years D. 6 years

A. 3 years At age 3, children can typically ascend stairs using alternating feet but still descend by placing both feet on each step.

A nurse is caring for an infant who has a tracheoesophageal fistula. Which of the following findings should the nurse expect? A. Coughing B. Apnea C. Sunken abdomen D. Cyanosis E. Frothy saliva

A, B, D, E

A nurse participating in lead screening at a community center. The nurse should instruct parents to bring their children back for rescreening in a year for which of the following laboratory values? A. 4 mcg/dL B. 10 mcg/dL C. 18 mcg/dL D. 44 mcg/dL

A. 4 mcg/dL A child who has a lead blood level of 4 mcg/dL should return in a year for rescreening.

A nurse is admitting a child who has leukemia. Which of the following clients should the nurse place in the same room with this child? A. A child who has nephrotic syndrome B. A child recovering from a ruptured appendix C. A child who has rheumatic fever D. A child who has cystic fibrosis

A. A child who has nephrotic syndrome A child who has leukemia is at risk for infection. Nephrotic syndrome is not an infectious disorder poses no risk to a child who has leukemia.

A nurse reports an incident of suspected child abuse. One of the parents of the child becomes upset and demands to know the reason for the nurse's action. Which of the following responses by the nurse is appropriate? A. "As a nurse, I am required by law to report suspected child abuse." B. "I am unable to discuss this, but I can contact my supervisor to speak with you." C. "The provider will be coming to explain the situation." D. "I reported the incident to my supervisor who decided to contact the authorities."

A. "As a nurse, I am required by law to report suspected child abuse." A nurse is required by law to report suspected child abuse. Therefore, this is a truthful, non-accusatory response.

A parent calls a clinic and reports to a nurse that his 2-month-old infant is hungry more than usual but is projectile vomiting immediately after eating. Which of the following responses should the nurse make? A. "Bring your baby in to the clinic today." B. "Burp your baby more frequently during feedings." C. "Give your infant an oral rehydration solution." D. "Try switching to a different formula."

A. "Bring your baby in to the clinic today." Projectile vomiting followed by hunger are characteristic of pyloric stenosis. The infant needs to be examined in the clinic by a provider as soon as possible.

A nurse is providing teaching to the parent of an infant who has gastroesophageal reflux. Which of the following statements by the parent indicates an understanding of the teaching? A. "I will keep my baby in an upright position after feedings." B. "My baby's formula can be thickened with oatmeal." C. "I will have to feed my baby formula rather than breast milk." D. "I should position my baby side-lying during sleep."

A. "I will keep my baby in an upright position after feedings." The infant should be maintained in an upright position for 1 hr after feedings.

A nurse is providing teaching to a parent of a child who has Hirschsprung disease and is scheduled for initial surgery. Which of the following statements by the parent indicates an understanding of the teaching? A. "I'm glad that my child's ostomy is only temporary." B. "I'm glad my child will have normal bowel movements now." C. "I want to learn how to use my child's feeding tube as soon as possible." D. "I want to learn how to empty my child's urinary catheter bag."

A. "I'm glad that my child's ostomy is only temporary." Hirschsprung disease is also known as aganglionic megacolon and is characterized by an area of the large intestine without nerve innervation. The child will probably require two surgeries over an 18- to 24-month period before normal bowel function is obtained. The initial surgery creates an ostomy, which relieves the obstructed area and allows the bowel distal to the ostomy to rest.

A nurse is providing nutritional teaching to the mother of a preschooler and is recommending food options to provide 1 oz of grains. Which of the following foods should the nurse recommend? A. 1 cup ready-to-eat cereal flakes B. 1/2 slice whole wheat bread C. 1 cup cooked rice D. 1/2 flour tortilla

A. 1 cup ready-to-eat cereal flakes The child should eat 1 cup of ready-to-eat cereal flakes to consume 1 oz of grains.

A nurse is caring for a 4-year-old child who has a new diagnosis of diabetes mellitus and is distressed after an insulin injection. Which of the following play activities should the nurse recognize is therapeutic in helping the child deal with the injection? A. A needleless syringe and a doll B. A video game C. A story book about a child who has diabetes D. A period of play in the playroom

A. A needleless syringe and a doll Playing with a needleless syringe and a doll is an appropriate therapeutic activity for the child, because they will allow the child to act out feelings of anger and helplessness.

A nurse is providing teaching to a parent of a preschooler who has eczema. Which of the following instructions should the nurse include in the teaching? A. Apply a topical corticosteroid ointment to the affected area. B. Launder the child's clothing with fabric softener. C. Give the child a bubble bath every day. D. Dress the child in woolen clothes during the cold months.

A. Apply a topical corticosteroid ointment to the affected area. The child might require a topical corticosteroid ointment to use during flare-ups to decrease inflammation.

A nurse is providing teaching about iron deficiency anemia to the parents of a toddler. Which of the following should the nurse recommend as a method of preventing iron deficiency anemia? A. Avoid a diet that consists primarily of milk. B. Administer fat-soluble vitamins daily. C. Include fluoridated water in the toddler's diet. D. Limit intake of high-protein foods.

A. Avoid a diet that consists primarily of milk. Milk is a poor source of iron and a diet that consists primarily of milk places the toddler at risk for iron deficiency anemia.

A nurse in an emergency department is caring for an infant who has a 2-day history of vomiting and an elevated temperature. Which of the following should the nurse recognize as the most reliable indicator of fluid loss? A. Body weight B. Skin integrity C. Blood pressure D. Respiratory rate

A. Body weight Body weight is the most reliable indicator of fluid loss for infants and young children.

A nurse is caring for a school-aged child who has a systemic disorder and is receiving antibiotics, immunosuppresants, and corticosteroids. Both of the child's parents have a smoking history. The child reports soreness in his mouth and refuses to eat. Inspection of his mouth reveals a white, milky plaque that does not come off with rubbing. The nurse should suspect which of the following conditions? A. Candidiasis B. Dermatitis C. Herpes simplex D. Squamous cell carcinoma

A. Candidiasis Manifestations of oral candidiasis include white patches that adhere to the inner cheeks, tongue, and palate that are painful and can cause the child to refuse to eat.

A nurse is providing health promotion teaching to the parents of an infant. Which of the following conditions should the nurse identify as the leading cause of death among this age group? A. Congenital anomalies B. Respiratory distress C. Low birth weight D. Sudden infant death syndrome

A. Congenital anomalies Congenital anomalies are the leading cause of infant mortality in the U.S.

A nurse is preparing to begin chest compressions on an infant. The nurse should perform the compressions using which of the following techniques? A. Deliver the compressions at 1/3 the depth of the chest. B. Deliver the compressions with the heel of one hand. C. Deliver compressions just above the nipple line. D. Deliver compressions at a depth of 5 cm (2in).

A. Deliver the compressions at 1/3 the depth of the chest. The proper depth of chest compressions for an infant is ⅓ the depth of the chest, which is approximately 1 ½ inches.

A child is admitted with a suspected diagnosis of Wilm's tumor. The nurse should place a sign with which of the following warnings over the child's bed? A. Do not palpate abdomen. B. No venipuncture or blood pressure in left arm. C. Contact precautions. D. Collect all urine.

A. Do not palpate abdomen. Wilms' tumor is a neoplasm of the kidney (nephroblastoma). This tumor is encapsulated, and palpation can cause it to rupture, which would allow seeding of the tumor into the pelvic cavity.

A nurse is caring for a 2-month-old infant who is postoperative following repair of a cleft lip and palate. The provider prescribes restraints. The nurse should apply which of the following types of restraints for this infant? A. Elbow B. Mummy C. Wrist D. Jacket

A. Elbow It is essential to apply elbow restraints immediately after surgery to keep the infant from rubbing the operative site. The nurse should remove the restraints periodically to inspect the skin and allow the infant arm exercise.

A nurse is caring for a 2-month-old infant who is postoperative following surgical repair of a cleft lip. Which of the following actions should the nurse take? A. Encourage the parents to rock the infant. B. Offer the infant a pacifier. C. Administer ibuprofen as needed for pain. D. Position the infant on her abdomen.

A. Encourage the parents to rock the infant. A rocking motion will calm and soothe the infant. Additionally, involving the parents in the infant's care can reduce feelings of helplessness.

A school nurse is assessing a school-aged child and notices white flakes that don't brush off the hair and a rash on the back of the child's neck. The nurse should suspect which of the following disorders? A. Pediculosis capitis B. Impetigo contagiosa C. Folliculitis D. Tinea capitis

A. Pediculosis capitis Pediculosis capitis is head lice, and its nits (eggs) are cemented to the hair shaft. The nits are silvery to white in color, similar to dandruff. They are typically seen on hair on the back of the head near the nape of the neck. A papular rash might be present at the nape of the neck secondary to scratching.

A nurse is caring for a child who ingested kerosene. Which of the following assessments is the nurse's priority? A. Respiratory rate B. Burns of the mouth C. Bowel sounds D. Visual acuity

A. Respiratory rate Using the airway, breathing, circulation approach to client care, the nurse should prioritize assessing the client's respiratory rate. Small amounts of kerosene can enter the lungs and damage them directly, causing a severe aspiration pneumonia. Because the pneumonia is caused by chemical irritation rather than bacteria, antibiotics aren't useful for prevention or treatment. Breathing becomes rapid and gasping, and vomiting and persistent coughing can follow. In severe cases, brain damage can occur.

A nurse is caring for a child who is admitted with suspected acute appendicitis. Which of the following manifestations should indicate to the nurse that the child's appendix is perforated? A. Sudden decrease in abdominal pain B. Absent Rovsing's sign C. Flaccid abdomen D. Low-grade fever

A. Sudden decrease in abdominal pain A sudden decrease in abdominal pain should indicate to the nurse that the appendix might be ruptured. If the appendix ruptures, the pain can disappear for a short period and the client might feel suddenly better. However, once peritonitis sets in, the pain returns and can spread into the whole abdomen.

A nurse is caring for a child who has Addison's disease. Which of the following actions should the nurse take? A. Teach the parents about cortisol replacement therapy. B. Place the child on a low-sodium diet. C. Monitor the child for fluid volume excess. D. Discuss the manifestations of hypoglycemia with the parents.

A. Teach the parents about cortisol replacement therapy. The nurse should plan to teach the child's parents about cortisol replacement therapy. Administration of glucocorticoids and mineralocorticoids is necessary because inadequate supplies or a sudden cessation of the medications can cause acute adrenal crisis.

A nurse is caring for a child who has otitis media. Which of the following assessment findings should the nurse expect? A. Tugging on the affected ear lobe B. Clear drainage from the affected ear C. Pain when manipulating the affected ear lobe D. Erythema and edema of the affected ear

A. Tugging on the affected ear lobe Otitis media is a middle ear infection. Expected findings include fever, purulent drainage (if the tympanic membrane is ruptured), and pain, demonstrated by the child tugging at the ear.

A nurse is providing teaching to an adolescent who has type 1 diabetes mellitus. Which of the following should the nurse include in the teaching? A. Administer glucagon for hyperglycemia. B. Obtain an influenza vaccine annually. C. Inject insulin into the deltoid muscle. D. Take glyburide with breakfast.

B. Obtain an influenza vaccine annually. The client should obtain an influenza vaccine annually.

A nurse is providing teaching about lice to the parents of a school-age child at a well-child visit. Which of the following information should the nurse include in the teaching? A. "Lice can jump from one child to another." B. "Encourage your child to avoid sharing hats with other children." C. "Live lice can survive for 2 weeks away from the host." D. "Washing your child's hair daily will prevent lice."

B. "Encourage your child to avoid sharing hats with other children." Lice are transmitted from person to person on personal items, such as hats, hair ornaments, scarves, combs, and brushes.

A nurse is providing teaching to a parent of a child who has a fracture of an epiphyseal plate. Which of the following statements should the nurse make? A. "The blood supply to the bone is disrupted." B. "Normal bone growth can be affected." C. "Bone marrow can be lost through the fracture." D. "The younger the child the longer the healing process will take."

B. "Normal bone growth can be affected." A fracture of the epiphyseal plate can affect growth in a child.

A nurse is teaching the parents of a toddler about temper tantrums. Which of the following statements should the nurse include in the teaching? A. "You should leave the room while the tantrum is happening." B. "Temper tantrums are the toddler's attempt to gain control of a situation." C. "You should get a psychological consult for the temper tantrums." D. "Temper tantrums are a type of learning disability."

B. "Temper tantrums are the toddler's attempt to gain control of a situation." Temper tantrums are a result of the toddler's frustration over his inability to control his environment. Temper tantrums occur because toddlers have not learned to control their emotions.

A nurse is admitting a 6-month-old infant who has dehydration. Which of the following amounts of urinary output should indicate to the nurse that the treatment has corrected the fluid imbalance? A. 0.5 mL/kg/hr B. 2 mL/kg/hr C. 7.5 mL/kg/hr D. 15 mL/kg/hr

B. 2 mL/kg/hr The expected urinary output for infants up to the age of 1 year is 2 mL/kg/hr. An infant who is not dehydrated should produce this amount of urine.

A nurse is assessing a toddler who has suspected lead poisoning. Which of the following findings should the nurse expect the client to manifest with acute lead poisoning? A. Increased urinary output B. Anorexia C. Diarrhea D. Jaundice

B. Anorexia Manifestations of acute lead poisoning include anorexia, nausea, vomiting, abdominal pain, and constipation.

A nurse is planning care for a 10-month-old infant who is 8 hr postoperative following cleft palate repair. Which of the following interventions should the nurse include in the infant's plan of care? A. Feed the infant with a spoon for 48 hr. B. Apply and release elbow restraints every hour. C. Keep the infant supine. D. Suction the mouth with an oral suction tube.

B. Apply and release elbow restraints every hour. It is essential to apply elbow restraints after surgery to keep the infant from placing her hands in and around her mouth. The nurse should remove them periodically to inspect the skin and allow the infant to exercise her arms.

A nurse is teaching a parent of a 2-year-old about safe food choices. Which of the following foods should the nurse recommend? A. Grapes B. Bananas C. Celery D. Raw carrots

B. Bananas Bananas are a safe choice for a 2-year-old child because they are easy to chew and swallow.

A nurse is admitting a child who has leukemia and a critically low platelet count. Which of the following precautions should the nurse initiate? A. Neutropenic B. Bleeding C. Contact D. Droplet

B. Bleeding The nurse should initiate bleeding precautions for a child who has a low platelet count. Bleeding precautions involve specific measures to reduce the risk of bleeding, such as using soft-bristled toothbrushes, avoiding IM injections, and preventing constipation.

A nurse is planning care for an adolescent who has scoliosis and requires surgical intervention. Which of the following behaviors by the adolescent should the nurse anticipate because it is most common reaction? A. Identity crisis B. Body image changes C. Feelings of displacement D. Loss of privacy

B. Body image changes Body image changes are the most common behaviors observed in adolescents who have scoliosis and require surgery.

A nurse is assessing a child who has nephrotic syndrome. Which of the following findings should the nurse expect? A. Polyuria B. Facial edema C. Smokey brown urine D. Hypertension

B. Facial edema The glomerular membrane is permeable to albumin, which is excreted and changes the colloidal osmotic pressure. Therefore, facial edema is a manifestation of nephrotic syndrome.

A parent of a toddler asks a nurse at a well-child visit how the child's frequent temper tantrums can best be handled. Which of the following actions should the nurse suggest to the parent? A. Restrain the child physically. B. Ignore the temper tantrums. C. Tell the child that temper tantrums are not acceptable. D. Distract the child by offering to play a game.

B. Ignore the temper tantrums. Ignoring a negative behavior is a basic concept in behavior modification. The parent should be instructed to make sure that the child is safe, and then appear to ignore the child or walk away. Without an audience, the behavior is more likely to extinguish itself quickly.

A nurse is caring for a 17-year-old client who is experiencing a relapse of leukemia and is refusing treatment. The client's mother insists that the client receive treatment. Which of the following actions should the nurse take? A. Initiate the IV per the parent's request. B. Notify the provider of the situation. C. Administer a sedative to calm the client. D. Offer the client and antiemetic.

B. Notify the provider of the situation. The nurse should consult with the provider before proceeding. Although the parent must give consent for a minor, the nurse should obtain the minor's assent when the minor is able to give it.

A nurse is assessing a child and notes several bruises. Which of the following actions should the nurse take? A. Report the suspected abuse to the authorities. B. Obtain a detailed history. C. Ask a psychiatrist to talk with the parents. D. Separate the child from the parents.

B. Obtain a detailed history. The nurse should obtain a detailed history in order to assess for other indicators of abuse.

A nurse is caring for an infant who has gastroesophageal reflux. The nurse should place the infant in which of the following positions following feedings? A. Place the infant in a prone position. B. Place the infant in an infant seat. C. Place the infant on his left side. D. Place the infant on his right side.

B. Place the infant in an infant seat. An infant seat provides elevation and decreases the risk of aspiration.

A nurse is caring for a child who has pertussis. The child's parent asks the nurse what the common name for this disease is. The nurse should respond with which of the following common names? A. Chickenpox B. Whooping cough C. Mumps D. Fifth disease

B. Whooping cough Whooping cough is the common name for pertussis

A nurse is caring for a child who has influenza. The nurse should identify that which of the following statements by the parent indicates the child has an increased risk for Reye syndrome? A. "I give my child ibuprofen when his muscles are aching." B. "I am encouraging my child to drink grapefruit juice." C. "I give my child aspirin to reduce his fever." D. "I am leaving a humidifier on in my child's room when he naps."

C. "I give my child aspirin to reduce his fever." The administration of aspirin for fever associated with a viral illness increases the child's risk for Reye syndrome. Reye syndrome is a metabolic encephalopathy with manifestations of cerebral edema and fatty changes in the liver.

A nurse is caring for a toddler who is 24 hour postoperative following a cleft palate repair. Which of the following actions should the nurse take? A. Offer fluids through a straw. B. Apply bilateral wrist restraints. C. Administer opioids for pain. D. Implement a soft diet.

C. Administer opioids for pain. Administering opioids for pain is an appropriate action by the nurse. Opioids control pain in the immediate postoperative period are followed by administration of acetaminophen PRN.

A nurse at a pediatrician's office is contacted by a parent whose child just ingested half a bottle of vitamins with added ferrous sulfate. Which of the following instructions should the nurse provide to the parent? A. Provide a high-carbohydrate meal. B. Give the child syrup of ipecac. C. Contact the poison control center. D. Bring the child to the office for a rapid infusion of deferoxamine.

C. Contact the poison control center. The nurse should instruct the parent to immediately notify the poison control center who will provide more detailed instructions.

A nurse in a pediatric clinic is caring for a child who has iron deficiency anemia and a new prescription for ferrous sulfate tablets. Which of the following instructions should the nurse provide the parents regarding administration of this medication? A. Give with a 240 mL (8 oz) glass of milk. B. Administer at mealtimes. C. Give with orange juice D. Administer at bedtime

C. Give with orange juice Citrus fruit or juice aids absorption of this medication.

A nurse is assessing a child who is in sickle cell crisis. Which of the following findings should the nurse expect? A. High fever B. Bradycardia C. Pain D. Constipation

C. Pain A client who is in sickle cell crisis has severe pain resulting from tissue hypoxia and necrosis.

A nurse is caring for a 6-week-old infant who has a pyloric stenosis. Which of the following clinical manifestations should the nurse expect? A. Red currant jelly stools B. Distended neck veins C. Projectile vomiting D. Ridged abdomen

C. Projectile vomiting Pyloric stenosis is a narrowing of the pylorus, the outlet from the stomach to the small intestine. The narrowing does not allow for emptying of the stomach contents. Vomiting, which is usually mild at first, becomes more forceful and progresses to projectile vomiting.

A nurse is caring for a child who has otitis media with effusion. The nurse should identify that which of the following manifestations indicates a tympanic membrane rupture? A. Green-blue discharge in the ear canal B. Increased temperature C. Sudden pain relief D. Popping sensation when swallowing

C. Sudden pain relief Accumulation of exudate caused by otitis media with effusion increases pressure behind the tympanic membrane. The pressure releases when the tympanic membrane ruptures, which results in sudden pain relief.

A school nurse is assessing an adolescent who reports feeling shaky and is having difficulty speaking and concentrating on the questions the nurse is asking. The nurse checks the adolescent's blood glucose level and identifies a value of 55 mg/dL. Which of the following findings should the nurse expect? A. Dry, flushed skin B. Deep, rapid respirations C. Tachycardia D. Polyuria

C. Tachycardia A blood glucose level of 55 mg/dL is below the expected reference range and an adolescent with this blood glucose level is likely to have tachycardia due to increased circulating catecholamines and increased adrenergic activity.

A nurse receives a call from a parent of a child who has von Willebrand disease and is having a nosebleed. Which of the following instructions should the nurse give to the parent? A. "Place your child in a sitting position with her head tilted back." B. "Apply ice at the base of the nose for 5 min and then check for bleeding." C. "Place your child in a supine position with a pillow under her back." D. "Have your child sit with her head tilted forward and hold pressure on her nose for 10 minutes."

D. "Have your child sit with her head tilted forward and hold pressure on her nose for 10 minutes." The nurse should instruct the parent to have the child sit up with her head tilted forward to reduce the risk of aspiration. The parent should apply pressure with the thumb and forefinger to the child's nose for 10 min and then check for further bleeding.

A nurse is teaching a parent of a child who has hemophilia how to control a minor bleeding episode. Which of the following statements by the parent indicates a need for further teaching? A. "I will have my child rest." B. "I will elevate the affected part." C. "I will compress the site." D. "I will apply heat."

D. "I will apply heat." Supportive measures to control a minor bleeding episode include applying cool compresses.

A nurse is providing discharge instructions to a parent and his school-age child who has juvenile idiopathic arthritis. Which of the following instructions should the nurse include? A. Encourage the child to take a 45 min nap daily. B. Allow the child to stay at home on days when her joints are painful. C. Apply cool compresses for 20 min every hour. D. Administer prednisone on an alternate-day schedule.

D. Administer prednisone on an alternate-day schedule. Prednisone is an effective anti-inflammatory agent that can have serious adverse effects. Taking prednisone on an alternate-day schedule can help maintain joint mobility and minimize adverse effects.

A nurse is caring for a child who has suspected appendicitis. Which of the following provider prescriptions should the nurse clarify? A. Maintain NPO status. B. Monitor oral temperature every 4 hr. C. Medicate the client for pain every 4 hr as needed. D. Administer sodium biphosphate/sodium phosphate.

D. Administer sodium biphosphate/sodium phosphate. Enemas and laxatives are contraindicated because they increase the volume in the bowel and can cause the inflamed appendix to rupture, increasing the risk for peritonitis.

A nurse in a pediatric unit is talking with the mother of a preschool-age child. The mother tells the nurse that her son is a "picky eater." Which of the following instructions should the nurse include in the teaching? A. Have the child remain at the table after meals to increase food intake. B. Add fruit juice to the child's diet to increase vitamin intake. C. Emphasize the quantity, rather than the quality, of food consumed. D. Expect that food consumption might not decrease significantly.

D. Expect that food consumption might not decrease significantly. Food consumption varies and most preschool-age children consume an adequate quantity of food despite their fads and preferences.

A nurse is providing teaching to a 17-year-old female client who has severe acne about the use of isotretinoin. Which of the following adverse effects should the nurse instruct the client is the priority to report to the provider? A. Frequent nosebleeds B. Itching of the skin C. Back pain D. Feelings of isolation

D. Feelings of isolation Feelings of isolation can indicate suicide ideation, which can lead to self-harm. Therefore, this adverse effect is the priority to report to the provider.

A nurse is assessing an adolescent who has an exacerbation of Graves' disease. Which of the following findings should the nurse expect? A. Weight gain B. Bradycardia C. Lethargy D. Heat intolerance

D. Heat intolerance An exacerbation of Graves' disease can cause heat intolerance due to an increased metabolic rate, which leads to warm flushed moist skin and extreme diaphoresis.

A nurse is planning care for an adolescent who is postoperative following scoliosis repair with Harrington rod instrumentation. Which of the following interventions should the nurse include in the plan of care? A. Keep the head of the bed at a 30 degree angle. B. Reposition the client by log rolling every 4 hrs. C. Place the client in protective isolation. D. Initiate the use of a PCA pump for pain control.

D. Initiate the use of a PCA pump for pain control. The nurse should initiate the use of a PCA pump for an adolescent who is postoperative following scoliosis repair. The PCA pump allows the client to control the delivery of pain medications.

A nurse is assessing a preschooler who has a calcium level of 8.0 mg/dL. Which of the following findings should the nurse expect? A. Dry, sticky mucous membranes B. Polyuria C. Negative Chvostek's sign D. Muscle tremors

D. Muscle tremors A serum calcium level of 8.0 mg/dL is below the expected reference range. A preschooler who has hypocalcemia is likely to have muscle tremors and cramps that can progress to tetany and convulsions.

A nurse is caring for a child who has acute gastroenteritis but is able to tolerate oral fluids. The nurse should anticipate providing which of the following types of fluid? A. Broth B. Water C. Diluted apple juice D. Oral rehydration solution

D. Oral rehydration solution Oral rehydration solution is the fluid of choice for infants and children who have dehydration due to diarrhea.

A nurse is planning care for a client who ingested a large amount of acetylsalicylic acid. Which of the following actions should the nurse take? A. Induce vomiting with syrup of ipecac. B. Administer N-acetylcysteine. C. Initiate chelation therapy with deferoxamine. D. Perform gastric lavage with activated charcoal.

D. Perform gastric lavage with activated charcoal. The nurse should plan to perform gastric lavage with activated charcoal, which acts to adsorb drugs and other chemicals in the gastrointestinal tract to prevent absorption into the bloodstream.

A nurse is caring for a toddler who has a fractured right femur and is in Bryant traction. When determining that the traction is appropriately assembled, the nurse should observe which of the following? A. Skin straps maintain the leg in an extended position. B. Weights are attached to a pin that is inserted into the femur. C. A padded sling is under the knee of the affected leg. D. The buttocks is elevated slightly off the bed.

D. The buttocks is elevated slightly off the bed. Having the buttocks elevated slightly off of the bed is appropriate for Bryant traction. The child's hips are flexed at a 90° angle with the legs suspended by pulleys and weights. The weights must hang freely from the bed to maintain alignment.